Traditional Vascular Risk Factors Research Articles

Clinical Predictors of Postmortem Amyloid and Nonamyloid Cerebral Small Vessel Disease in Middle-Aged to Older Adults.

Sporadic cerebral small vessel disease (CSVD) is a class of important pathologic processes known to affect the aging brain and to contribute to cognitive impairment. We aimed to identify clinical risk factors associated with postmortem CSVD in middle-aged to older adults. We developed and tested risk models for their predictive accuracy of a pathologic diagnosis of nonamyloid CSVD and cerebral amyloid angiopathy (CAA) in a retrospective sample of 160 autopsied cases from the Edinburgh Brain Bank. Individuals aged 40 years and older covering the spectrum of healthy aging and common forms of dementia (i.e., highly-prevalent etiologies such as Alzheimer disease (AD), vascular cognitive impairment (VCI), and mixed dementia) were included. We performed binomial logistic regression models using sample splitting and cross-validation methods. Demographics, lifestyle habits, traditional vascular risk factors, chronic medical conditions, APOE4, and cognitive status were assessed as potential predictors. Forty percent of our sample had a clinical diagnosis of dementia (AD = 33, VCI = 26 and mixed = 5) while others were cognitively healthy (n = 96). The mean age at death was 73.8 (SD 14.1) years, and 40% were female. The presence of none-to-mild vs moderate-to-severe nonamyloid CSVD was predicted by our model with good accuracy (area under the curve [AUC] = 0.84, sensitivity [SEN] = 72%, specificity [SPE] = 95%), with the most significant clinical predictors being age, history of cerebrovascular events, and cognitive impairment. The presence of CAA pathology was also predicted with high accuracy (AUC = 0.86, SEN = 93%, SPE = 79%). Significant predictors included alcohol intake, history of cerebrovascular events, and cognitive impairment. In a subset of atypical dementias (n = 24), our models provided poor predictive performance for both nonamyloid CSVD (AUC = 0.50) and CAA (AUC = 0.43). CSVD pathology can be predicted with high accuracy based on clinical factors in patients within the spectrum of AD, VCI, and normal aging. Whether this prediction can be enhanced by the addition of fluid and neuroimaging biomarkers warrants additional study. Improving our understanding of clinical determinants of vascular brain health may lead to novel strategies in the prevention and treatment of vascular etiologies contributing to cognitive decline. This study provides Class II evidence that selected clinical factors accurately distinguish between middle-aged to older adults with and without cerebrovascular small vessel disease (amyloid and nonamyloid) pathology.

Ischemic Stroke in Young Tunisian Adults.

Ischemic Stroke in young adults is a real public health problem; it's a major cause of disability, alters quality of life and has a great socio-economic impact. determine risk factors and specify the etiology of arterial ischemic stroke in young Tunisian adults. In this 5 years retrospective study (2015-2020), we included all young adults (18-50 years) admitted for arterial ischemic stroke (AIS). Risk factors were registered and analyzed. All patients were investigated using a standard protocol: biological tests, brain imaging, carotid ultrasound and cardiac assessment. Additional investigations were carried out at the discretion of the treating physician. The cause of ischemic stroke was classified according to the TOAST criteria. We collected 200 patients with AIS. The mean age was 41.37 years ± 6.99. Traditional vascular risk factors were observed in more than 1⁄4 patients. A definite cause of stroke was identified in 120 patients. Cardio-embolic causes were the most common among our patients (19%) followed by atherosclerosis of the large arteries (11.5%). Other determined etiologies were found in 27.5% of patients. The etiology remained unclear in 40% of cases: undetermined despite complete investigation in 17.5%, undetermined and incompletely investigated 14.5 % and more than one potential pathomechanisms in 8%. Through this study, we demonstrated the diversity of etiology of stroke in young Tunisian adults. Changes of lifestyle are responsible for the occurrence of the traditional risk factors at an early age. Rheumatic heart diseases remain a frequent cause of AIS in our area.

The clinical significance of arterial stiffness in the differential diagnosis of vertigo

Objectives: Pulse wave velocity (PWV) is a known indicator of arterial stiffness reflecting vascular damage. However, there are few reports of the relationship between PWV and dizziness/vertigo of a vascular origin. We investigated whether the PWV value could be useful as an ancillary measurement for identifying the etiology of dizziness/vertigo.Methods: We enrolled dizzy patients from March 2016 to December 2018. The patients with posterior circulation stroke presenting with dizziness/vertigo were categorized as having central vertigo. The patients with vertigo due to benign paroxysmal positional vertigo, Ménière disease, or acute unilateral vestibulopathy were categorized as having peripheral vertigo. The PWV value, ankle-brachial index (ABI), and traditional vascular risk factors were collected.Results: We consecutively enrolled a total of 93 participants. The PWV values were higher in the central vertigo group (p<0.001), but ABI did not differ between the groups. Among the vascular risk factors, the number of patients with diabetes mellitus, dyslipidemia, and male patients was significantly higher in the central vertigo group. The brachial-ankle PWV (baPWV) values were higher in the central vertigo group, even after adjusting for confounding factors (p<0.01). The receiver operating characteristic curve showed that the sensitivity was 74% and specificity was 81% when the mean baPWV value was 14.78 m/sec.Conclusions: Increased baPWV values were observed in patients with dizziness/vertigo due to stroke. Measurement of the baPWV value could be an ancillary test for evaluating the cause of dizziness/vertigo, even though more convincing evidence is still required.

Stroke frequency, associated factors, and clinical features in primary systemic vasculitis: a multicentric observational study.

The cerebral vessels may be affected in primary systemic vasculitis (PSV), but little is known about cerebrovascular events (CVEs) in this population. This study aimed to determine the frequency of CVEs at the time of diagnosis of PSV, to identify factors associated with CVEs in PSV, and to explore features and outcomes of stroke in patients with PSV. Data from adults newly diagnosed with PSV within the Diagnostic and Classification Criteria in VASculitis (DCVAS) study were analysed. Demographics, risk factors for vascular disease, and clinical features were compared between patients with PSV with and without CVE. Stroke subtypes and cumulative incidence of recurrent CVE during a prospective 6-month follow-up were also assessed. The analysis included 4828 PSV patients, and a CVE was reported in 169 (3.50%, 95% CI 3.00-4.06): 102 (2.13% 95% CI 1.73-2.56) with stroke and 81 (1.68% 95% CI 1.33-2.08) with transient ischemic attack (TIA). The frequency of CVE was highest in Behçet's disease (9.5%, 95% CI 5.79-14.37), polyarteritis nodosa (6.2%, 95% CI 3.25-10.61), and Takayasu's arteritis (6.0%, 95% CI 4.30-8.19), and lowest in microscopic polyangiitis (2.2%, 95% CI 1.09-3.86), granulomatosis with polyangiitis (2.0%, 95% CI 1.20-3.01), cryoglobulinaemic vasculitis (1.9%, 95% CI 0.05-9.89), and IgA-vasculitis (Henoch-Schönlein) (0.4%, 95% CI 0.01-2.05). PSV patients had a 11.9% cumulative incidence of recurrent CVE during a 6-month follow-up period. CVEs affect a significant proportion of patients at time of PSV diagnosis, and the frequency varies widely among different vasculitis, being higher in Behçet's. Overall, CVE in PSV is not explained by traditional vascular risk factors and has a high risk of CVE recurrence.

Abstract 96: Temporal Trends in Vascular Risk Factor Burden Among Young Adults With Ischemic Stroke: The Florida Stroke Registry

Introduction: While ischemic stroke (IS) in the young (18-55) is thought to have different etiologies than in older patients, a rise in vascular risk factors (VRFs) among young adults may translate to an IS risk profile similar to the older population. We aimed to examine the prevalence of VRFs and temporal trends in VRF burden among young patients presenting with IS. Methods: Data was prospectively collected by Get With the Guidelines-Stroke® hospitals participating in the Florida Stroke Registry between January 2010 and December 2022. Patients aged 18-55 with a diagnosis of IS were included and separated into two age groups: 18-35 and 36-55. VRFs included hypertension, dyslipidemia, obesity, smoking, atrial fibrillation, coronary artery disease, heart failure, diabetes, and sleep apnea. Multimorbidity was defined as having ≥4 VRFs. Results: 47,792 patients with IS were included (43% female, median age 49, 51% white), comprising 4,275 patients aged 18-35 (8.9%) and 43,517 aged 36-55 (91.1%). The prevalence of each VRF was higher among patients aged 36-55 vs 18-35 (all p values <0.001), and only 15.3% of patients aged 36-55 and 40.0% of patients aged 18-35 had 0 VRFs. African American patients with IS had a significantly higher prevalence of multimorbidity than white or non-white Hispanic patients; specifically in those aged 18-35 (6.1% vs 3.5% vs 3.5%, p <0.001), while those aged 36-55 demonstrated a smaller difference (17.6% vs 17.2% vs 15.4% p <0.001).VRF burden worsened across the study period, with an increase in multimorbidity from 11.2% to 21.7% in patients 36-55 (p<0.0001) and from 1.3% to 6.6% in patients 18-35 (p= 0.0006). Conclusions: Increasingly, young stroke patients have traditional VRFs. The prevalence of multimorbidity disproportionately affects African American patients and has significantly increased over the past 12 years. Efforts targeting VRFs reduction must start as early as possible in light of the rise in VRF burden amongst young IS patients.

Abstract WP170: Patients With Cerebral Microbleeds Are More Likely to Have Poor Collaterals at the Time of Mechanical Thrombectomy

Introduction: Collateral cerebrovasculature is important for the survival of penumbral tissue in patients with large vessel occlusive (LVO) stroke, and adequate collateralization is associated with favorable outcomes. The presence of cerebral microbleeds (CMB) have been implicated in vessel wall remodeling and impaired vasoreactivity. We investigated whether the presence of deep and/or lobar CMB predicts poor collateral recruitment in patients with LVO stroke who underwent thrombectomy (MT). Methods: We performed a retrospective, single-center study of adults who presented with LVO stroke and had MT between January 2012-June 2020. CT angiography of head prior to MT was used to assess collateral status with poor status defined as ≤50% filling and good status as >50% filling. CMBs were assessed using T2*-weighted gradient echo or susceptibility weighted magnetic resonance images. Location of CMB was further characterized as deep vs. lobar using consensus definitions. Poor stroke outcome was defined as modified Rankin Scale (mRS) ≥3 at 90 days. Multivariable logistic regressions were performed to evaluate the associations between CMB, CMB types (lobar, deep, lobar+deep) and poor collaterals after adjusting for vascular risk factors. Results: Consecutive 151 subjects were included (mean age 68±15 years, 47% women), with a median NIHSS of 18. CMB were identified in 57 subjects (37.4%). Of these, 20.5% had lobar CMB, 5.3% had deep CMB and 11.9% had combined lobar & deep CMB. Patients with CMB had higher odds of having poor collaterals compared to those without CMB (OR 1.56, 95% CI 1.09-2.23, P=0.015). The association of CMB with poor collaterals was strongest in patients with combined lobar & deep CMB (OR 4.78, 95% CI 1.43-15.93, P=0.011), compared with those with exclusively deep CMB (OR 2.78, 95% CI 0.44-17.62, P=0.278) or lobar CMB (OR 0.52, 95% CI 0.19-1.38, P=0.188). Patients with poor collaterals were more likely to have poor outcome compared with those with good collaterals (48.4% vs. 31.0%, P=0.03). Conclusion: Cerebral microbleeds are independently associated with poor collateral recruitment when adjusted for traditional vascular risk factors. Further study is warranted to elucidate the differential effects of CMB types on collateral recruitment.

Exploring the Chagas Disease-Stroke “Connection”: Findings from a Large Multicenter Study

Introduction: Strokes are traditionally attributed to risk factors like aging, hypertension, diabetes, and atherosclerosis. Chagas disease has emerged as an important risk factor for stroke in Latin American. Our study aims at describing the largest cohort of patients with Chagas disease and ischemic stroke and determining variables associated with stroke recurrence and cardioembolic cause. Methods: This study is the result of a national multicenter cohort study conducted in Brazil. The study spanned from January 2009 to December 2016 and involved a comprehensive retrospective analysis of medical records of patients with both Chagas disease and stroke. This cohort comprised 499 individuals from diverse Brazilian regions, focusing on vascular risk factors and the epidemiological variables associated with Chagas disease and stroke. Results: Our findings underscore the significant prevalence of traditional vascular risk factors among Chagas disease patients who had stroke. 81% of patients had hypertension, 56% dyslipidemia, and 25% diabetes. We observed a 29.7% recurrence rate, especially within the cardioembolic subgroup. 56% of the patients had embolic stroke of undetermined source (ESUS). Specific electrocardiography abnormalities were associated with an increased risk of cardioembolic etiology (with three altered results increasing 81 fold the chance of the stroke being of cardioembolic nature). Age emerged as a protective factor (OR: 0.98, 95% confidence interval [CI]: 0.970–0.997) against cardioembolic etiology. Anticoagulation therapy was associated with reduced risk (OR: 0.221, 95% CI 0.104–0.472), highlighting the importance of accurate etiological classification. Conversely, female gender (OR: 1.83, 95% CI: 1.039–3.249) emerged as a significant risk factor for stroke recurrence. Conclusion: This study significantly advances our epidemiological understanding of the intersection between Chagas disease and stroke. It emphasizes the critical need for extensive epidemiological investigations, a deeper comprehension of stroke recurrence determinants, and accurate etiological classification to reduce the ESUS population. Our findings have substantial clinical implications, suggesting the need of control of vascular risk factors and comorbidities and hold promise for improving patient care and reducing the burden of Chagas disease and stroke worldwide.

Ischemic stroke in men 18-50 years of age

To evaluate the main modifiable risk factors for ischemic stroke (IS) and features of the course in atherothrombotic, cardioembolic, and lacunar subtypes of IS in men aged 18-50 years. The study included 125 men (the mean age was 42.6±5.3 years) who were admitted to the Vascular department before the COVID-19 pandemic and survived for the first 30 days after IS. Information on patients' baseline characteristics, traditional vascular risk factors, and lifestyle risk factors was systematically collected. Neuroimaging, ultrasound and laboratory tests were performed. Atherothrombotic subtype was identified in 60 patients, lacunar subtype in 46 patients and cardioembolic subtype in 19 patients. In the group as a whole, major risk factors included arterial hypertension (83.2%), dyslipidemia (50.4%), smoking (67.2%), alcohol consumption (29.6%), obesity (16.8%), heart rhythm disorders (12%), and diabetes mellitus (8%). The study revealed the main risk factors, the frequency of which differed depending on the stroke subtype and the age of the patients.

Lifetime influences on imaging markers of adverse brain health and vascular disease

Cerebral small vessel disease (cSVD) is highly prevalent in the general population, increases with age and vascular risk factor exposure, and is a common cause of stroke and dementia. There is great variation in cSVD burden experienced in older age, and maintaining brain health across the life course requires looking beyond an individual's current clinical status and traditional vascular risk factors. Of particular importance are social determinants of health which can be more important than healthcare or lifestyle choices in influencing later life health outcomes, including brain health. In this paper we discuss the social determinants of cerebrovascular disease, focusing on the impact of socioeconomic status on markers of cSVD. We outline the potential mechanisms behind these associations, including early life exposures, health behaviours and brain reserve and maintenance, and we highlight the importance of public health interventions to address the key determinants and risk factors for cSVD from early life stages.

Risk Factors Associated with Epilepsy Related to Cerebrovascular Disease: A Systematic Review and Meta-Analysis.

Stroke is one of the most frequent neurological syndromes in the adult population and the cause of 10% of all diagnosed epilepsies. It is attributed to the origin of up to 50% of them in adults >60 years of age. Although a few risk factors have been described and considered when modeling predictive tools, this aspect is still clinically complex. The objective of this study is to describe and compare predictor scales of post stroke epilepsy (PSE) in adult patients with better performance. A systematic review and meta-analysis were performed of studies published between 2010 and 2020 and found in PubMed, Scopus, EMBASE, LILACS, BVS, Google Scholar, and CENTRAL databases. Sixteen studies were included with a total of 298,694 patients with a diagnosis of stroke, 5590 presented late seizures (LS). Hemorrhage, cortical involvement, and early seizure were the elements most associated with the risk of presenting late seizures. The SeLECT score demonstrated a low risk of bias with a high predictive ability in patients with ischemic stroke (AUC: 0.77 [95% CI: 0.71-0.82]). In patients with hemorrhagic stroke, the CAVE score demonstrated adequate predictive ability (AUC: 0.81 [95% CI: 0.76-0.86]), but an uncertain risk of bias. Research has established risk factors for post ictal epilepsy; however, the numerous ways of assessing data in studies and the difference in their designs make the task of producing a predictive scale that covers the most important risk factors and is reliable for application in the clinical setting, regardless of stroke etiology, very arduous. Hemorrhage, cortical involvement, and early seizure are associated with an increased risk of post ictal epilepsy. Also, elements such as age, traditional vascular risk factors, and functional assessment failed to reflect statistical significance. Finally, further research is required to refine the available predictive tools.

Chromosome 10q24.32 Variants Associate With Brain Arterial Diameters in Diverse Populations: A Genome-Wide Association Study.

Brain arterial diameters (BADs) are novel imaging biomarkers of cerebrovascular disease, cognitive decline, and dementia. Traditional vascular risk factors have been associated with BADs, but whether there may be genetic determinants of BADs is unknown. The authors studied 4150 participants from 6 geographically diverse population-based cohorts (40% European, 14% African, 22% Hispanic, 24% Asian ancestries). Brain arterial diameters for 13 segments were measured and averaged to obtain a global measure of BADs as well as the posterior and anterior circulations. A genome-wide association study revealed 14 variants at one locus associated with global BAD at genome-wide significance (P<5×10-8) (top single-nucleotide polymorphism, rs7921574; β=0.06 [P=1.54×10-8]). This locus mapped to an intron of CNNM2. A trans-ancestry genome-wide association study meta-analysis identified 2 more loci at NT5C2 (rs10748839; P=2.54×10-8) and AS3MT (rs10786721; P=4.97×10-8), associated with global BAD. In addition, 2 single-nucleotide polymorphisms colocalized with expression of CNNM2 (rs7897654; β=0.12 [P=6.17×10-7]) and AL356608.1 (rs10786719; β=-0.17 [P=6.60×10-6]) in brain tissue. For the posterior BAD, 2 variants at one locus mapped to an intron of TCF25 were identified (top single-nucleotide polymorphism, rs35994878; β=0.11 [P=2.94×10-8]). For the anterior BAD, one locus at ADAP1 was identified in trans-ancestry genome-wide association analysis (rs34217249; P=3.11×10-8). The current study reveals 3 novel risk loci (CNNM2, NT5C2, and AS3MT) associated with BADs. These findings may help elucidate the mechanism by which BADs may influence cerebrovascular health.

Is coronary artery calcium an independent risk factor for white matter hyperintensity?

BackgroundCardiovascular diseases have been considered the primary cause of disability and death worldwide. Coronary artery calcium (CAC) is an important indicator of the severity of coronary atherosclerosis. This study is aimed to investigate the relationship between CAC and white matter hyperintensity (WMH) in the context of diagnostic utility.MethodsA retrospective analysis was conducted on 342 patients with a diagnosis of WMH on magnetic resonance images (MRI) who also underwent chest computed tomography (CT) scans. WMH volumes were automatically measured using a lesion prediction algorithm. Subjects were divided into four groups based on the CAC score obtained from chest CT scans. A multilevel mixed-effects linear regression model considering conventional vascular risk factors assessed the association between total WMH volume and CAC score.ResultsOverall, participants with coronary artery calcium (CAC score > 0) had larger WMH volumes than those without calcium (CAC score = 0), and WMH volumes were statistically different between the four CAC score groups, with increasing CAC scores, the volume of WMH significantly increased. In the linear regression model 1 of the high CAC score group, for every 1% increase in CAC score, the WMH volume increases by 2.96%. After including other covariates in model 2 and model 3, the β coefficient in the high CAC group remains higher than in the low and medium CAC score groups.ConclusionIn elderly adults, the presence and severity of CAC is related to an increase in WMH volume. Our findings suggest an association between two different vascular bed diseases in addition to traditional vascular risk factors, possibly indicating a comorbid mechanism.

Trimethylamine N-Oxide and White Matter Hyperintensity Volume Among Patients With Acute Ischemic Stroke

Although increasing evidence suggests that trimethylamine N-oxide (TMAO) is associated with atherosclerosis, little is known about whether TMAO and its related metabolites (ie, choline, betaine, and carnitine) are associated with small vessel disease. To evaluate the association between TMAO and its related metabolites with features of cerebral small vessel disease, including white matter hyperintensity volume (WMHV) and acute lacunar infarction. This cross-sectional study included patients enrolled in the Specialized Programs of Translational Research in Acute Stroke biorepository. The registry included 522 patients with acute ischemic stroke who were 18 years or older who presented at the Massachusetts General Hospital or Brigham and Women's Hospital within 9 hours after onset between January 2007 and April 2010. The analyses in this study were conducted between November 2022 and April 2023. Plasma TMAO, choline, betaine, and carnitine were measured by liquid chromatography-tandem mass spectrometry. WMHV was quantified by a semiautomated approach using signal intensity threshold with subsequent manual editing. Ischemic stroke subtype was classified using the Causative Classification System. Among 351 patients included in this study, the mean (SD) age was 69 (15) years; 209 patients (59.5%) were male and had a median (IQR) admission National Institute of Health Stroke Scale of 6 (3-13). The magnetic resonance imaging subgroup consisted of 291 patients with a mean (SD) age of 67 (15) years. Among these, the median (IQR) WMHV was 3.2 (1.31-8.4) cm3. TMAO was associated with WMHV after adjustment for age and sex (β, 0.15; 95% CI, 0.01-0.29; P < .001). TMAO remained significant in a multivariate analysis adjusted for age, sex, hypertension, diabetes, and smoking (β, 0.14; 95% CI, 0-0.29; P = .05). TMAO was associated with lacunar stroke but not other ischemic stroke subtypes in a model adjusted for age, sex, hypertension, diabetes, and smoking (OR, 1.67; 95% CI, 1.05-2.66; P = .03). In this observational study, TMAO was associated with cerebral small vessel disease determined by WMHV and acute lacunar infarction. The association was independent of traditional vascular risk factors.

The Positional Relationship between Lacunae and White Matter Hyperintensity in Patients with Cerebral Small Vessel Disease.

Lacunae and white matter hyperintensity (WMH) are two crucial imaging biomarkers of cerebral small vessel disease (CSVD). Multiple studies have revealed a close relationship between WMH and lacunae and found that a double penumbra existed at the edge of WMH that affects lacunae formation. The study aimed to explore the spatial distribution characteristics and possible influencing factors of lacuna in relation to white matter hyperintensity in patients with CSVD. A total of 480 CSVD patients with WMH and with or without lacunae were included. Data about blood biochemical indicators, cerebrovascular CT angiography, 24-hour ambulatory blood pressure and ambulatory electrocardiogram, brain magnetic resonance imaging, and transcranial Doppler ultrasound were gathered from all subjects. They were categorised into four groups based on the spatial interaction between lacunae and WMH. Univariate analyses and multiple logistic regression analyses were used to compare the differences in traditional vascular risk factors, heart rate and blood pressure indicators, arterial pulsatility index (PI) values, and arterial stenosis among different groups. The average age of 480 patients was (58.63 ± 11.91) years, with 347 males (72.3%). Univariate analysis indicated that age, fasting blood glucose, triglycerides, total cholesterol, highdensity lipoprotein, 24-hour and daytime and night systolic and diastolic blood pressure, nocturnal heart rate, heart rate variability, PI values of ipsilateral and contralateral MCA (middle cerebral artery) and ICA (Internal carotid artery) of the lacunae, Fazekas score of PWMH (periventricular white matter hyperintensities), the proportion of MCA or ICA with stenosis rate over 50% on the ipsilateral side of the lacunae were significantly different between different groups (p < 0.05). High fasting blood glucose (OR=1.632, 95% CI= (1.128, 2.361), p =0.009), (OR=1.789, 95%CI= (1.270, 2.520), p = 0.001), (OR=1.806, 95% CI= (1.292, 2.524), p =0.001) was identified as a risk factor for lacunae formation by logistic regression analysis. High fasting blood glucose can be considered a risk factor for lacunae formation in patients with WMH. The more severe the PWMH and the higher the nocturnal heart rate, the more likely the lacunae, as well as PWMH, overlap completely. Ipsilateral arteriosclerosis and stenosis are independent risk factors for no contact between lacunae and PWMH.

Neuroticism personality traits are linked to adverse cardiovascular phenotypes in the UK Biobank.

To evaluate the relationship between neuroticism personality traits and cardiovascular magnetic resonance (CMR) measures of cardiac morphology and function, considering potential differential associations in men and women. The analysis includes 36 309 UK Biobank participants (average age = 63.9 ± 7.7 years; 47.8% men) with CMR available and neuroticism score assessed by the 12-item Eysenck Personality Questionnaire-Revised Short Form. CMR scans were performed on 1.5 Tesla scanners (MAGNETOM Aera, Siemens Healthcare, Erlangen, Germany) according to pre-defined protocols and analysed using automated pipelines. We considered measures of left ventricular (LV) and right ventricular (RV) structure and function, and indicators of arterial compliance. Multivariable linear regression was used to estimate association of neuroticism score with individual CMR metrics, with adjustment for age, sex, obesity, deprivation, smoking, diabetes, hypertension, hypercholesterolaemia, alcohol use, exercise, and education. Higher neuroticism scores were associated with smaller LV and RV end-diastolic volumes, lower LV mass, greater concentricity (higher LV mass to volume ratio), and higher native T1. Greater neuroticism was also linked to poorer LV and RV function (lower stroke volumes) and greater arterial stiffness. In sex-stratified analyses, the relationships between neuroticism and LV stroke volume, concentricity, and arterial stiffness were attenuated in women. In men, association (with exception of native T1) remained robust. Greater tendency towards neuroticism personality traits is linked to smaller, poorer functioning ventricles with lower LV mass, higher myocardial fibrosis, and higher arterial stiffness. These relationships are independent of traditional vascular risk factors and are more robust in men than women.

Psychological stress is associated with arterial inflammation in people living with treated HIV infection

Stress and depression are increasingly recognized as cerebrovascular risk factors, including among high stress populations such as people living with HIV infection (PLWH). Stress may contribute to stroke risk through activation of neural inflammatory pathways. In this cross-sectional study, we examined the relationships between stress, systemic and arterial inflammation, and metabolic activity in stress-related brain regions on 18F-fluorodeoxyglucose (FDG)-PET in PLWH. Participants were recruited from a parent trial evaluating the impact of alirocumab on radiologic markers of cardiovascular risk in people with treated HIV infection. We administered a stress battery to assess different forms of psychological stress, specifying the Perceived Stress Scale as the primary stress measure, and quantified plasma markers of inflammation and immune activation. Participants underwent FDG-PET of the brain, neck, and chest. Age- and sex-matched control participants without HIV infection were selected for brain FDG-PET comparisons. Among PLWH, we used nonparametric pairwise correlations, partial correlations, and linear regression to investigate the association between stress and 1) systemic inflammation; 2) atherosclerotic inflammation on FDG-PET; and metabolic activity in 3) brain regions in which glucose metabolism differed significantly by HIV serostatus; and 4) in a priori defined stress-responsive regions of interest (ROI) and stress-related neural network activity (i.e., ratio of amygdala to ventromedial prefrontal cortex or temporal lobe activity). We studied 37 PLWH (mean age 60 years, 97% men) and 29 control participants without HIV (mean age 62 years, 97% men). Among PLWH, stress was significantly correlated with systemic inflammation (r = 0.33, p = 0.041) and arterial inflammation in the carotid (r = 0.41, p = 0.023) independent of age, race/ethnicity, traditional vascular risk factors and health-related behaviors. In voxel-wise analyses, metabolic activity in a cluster corresponding to the anterior medial temporal lobes, including the bilateral amygdalae, was significantly lower in PLWH compared with controls. However, we did not find a significant positive relationship between stress and this cluster of decreased metabolic activity in PLWH, a priori defined stress-responsive ROI, or stress-related neural network activity. In conclusion, psychological stress was associated with systemic and carotid arterial inflammation in this group of PLWH with treated infection. These data provide preliminary evidence for a link between psychological stress, inflammation, and atherosclerosis as potential drivers of excess cerebrovascular risk among PLWH.

AORTIC STIFFNESS IS INDEPENDENTLY ASSOCIATED WITH INTRACRANIAL CAROTID ARTERY CALCIFICATION IN PATIENTS WITH ISCHEMIC STROKE

Objective: Intracranial carotid artery calcification (ICAC), as a strong contributor to the occurrence of ischemic stroke, might be present in the medial or intimal arterial layer. Traditional vascular risk factors are associated with ICAC; however, its association with new markers of vascular function are less understood. The paper aims to evaluate the relationship between carotid-femoral pulse wave velocity (CF-PWV) and ICAC subtypes. Design and method: We enrolled 65 patients with acute ischemic stroke. CF-PWV, systolic, diastolic and mean blood pressure, and pulse pressure (SBP, DBP, MBP, PP) were measured within 6±2 days of stroke onset. CT was performed within 24 hours of stroke onset and ICAC on the stroke site was classified by two methods: volume- and score-based. Tertiles of ICAC volume were determined, and low-grade ICAC (T1) was regarded as a reference. According to the score-based method, medial and intimal ICAC subtypes were determined. Data were analyzed with multivariate logistic regression. Results: Medial and intimal ICAC subtypes were found in 34 (52%) and 24 (37%) patients, respectively. In 11% of patients no ICAC calcifications were found. CF-PWV was higher in patients with high-grade ICAC (OR = 1.56, 95%CI = 1.03-2.35, p = 0.035). CF-PWV was higher in patients with the medial ICAC subtype than in patients with the intimal ICAC subtype (OR = 1.60, 95%CI = 1.00-2.55, p = 0.049) after adjustment for age, MBP, diabetes mellitus, arterial hypertension, hyperlipidemia, and smoking status. Conclusions: Our study demonstrates that among patients with ischemic stroke, aortic stiffness is independently associated with ICAC, and that medial ICAC, compared with intimal ICAC, is accompanied by more advanced aortic stiffness.

Contribution of Migraine to Cardiovascular Disease Risk Prediction

BackgroundMigraine with aura (MA) is associated with cardiovascular disease (CVD) independently from traditional vascular risk factors. However, the importance of MA on CVD occurrence relative to existing cardiovascular prediction tools remains unclear. ObjectivesIn this study, we sought to determine if adding MA status to 2 CVD risk prediction models improves risk prediction. MethodsParticipants enrolled in the Women’s Health Study self-reported MA status and were followed for incident CVD events. We included MA status as a covariable in the Reynolds Risk Score and the American Heart Association (AHA)/American College of Cardiology (ACC) pooled cohort equation and assessed discrimination (Harrell c-index), continuous and categorical net reclassification improvement (NRI), and integrated discrimination improvement (IDI). ResultsMA status was significantly associated with CVD after including covariables in the Reynolds Risk Score (HR: 2.09; 95% CI: 1.54-2.84) and the AHA/ACC score (HR: 2.10; 95% CI: 1.55-2.85). Adding information on MA status improved discrimination of the Reynolds Risk Score model (from 0.792 to 0.797; P = 0.02) and the AHA/ACC score model (from 0.793 to 0.798; P = 0.01). We observed a small but statistically significant improvement in the IDI and continuous NRI after adding MA status to both models. We did not, however, observe significant improvements in the categorical NRI. ConclusionsAdding information on MA status to commonly used CVD risk prediction algorithms enhanced model fit but did not substantially improve risk stratification among women. Despite the strong association of migraine with CVD risk, the relatively low prevalence of MA compared with other CV risk factors limits its usefulness in improving risk classification at the population level.

Trapdoor Endarterectomy for Coral Reef Plaque of the Paravisceral Aorta in the Modern Era

Coral reef atherosclerosis (CRA) of the paravisceral aorta is a rare disease whose description is largely confined prior to contemporary vascular surgical techniques. This study aims to describe the characteristics and outcomes of patients with CRA treated with trapdoor endarterectomy (TEA) at a single high-volume quaternary referral center since 2010. From 2010 to 2022, 14 patients were identified who underwent TEA for symptomatic CRA. Data on patient demographics, operative details, hospital course, and outpatient follow-up were obtained via retrospective chart review. Patients were predominantly female (71%) with a median age of 65 years (interquartile range [IQR], 63-70) and had traditional vascular risk factors. Over 85% had previously diagnosed carotid stenosis; two patients (14%) had prior aortofemoral reconstruction, and one (7%) had prior axillobifemoral bypass. The most common presenting symptoms were claudication (64%), chronic mesenteric ischemia (50%), and renovascular hypertension (43%). Eight patients (57%) received isolated TEA and six (43%) received concomitant aortobifemoral bypass (Table I). Thirteen patients (93%) required a supraceliac aortic clamp position with a median clamp time of 26 minutes (IQR, 20-30 minutes). Median estimated blood loss was 1650 mL (IQR, 1025-3750 mL). Cell saver was used in 13 procedures (93%) with median transfusion of 563 mL (IQR, 231-900 mL). Median operative time was 341 minutes (IQR, 315-316 minutes). Eight patients (57%) had acute kidney injury in the postoperative period with peak creatinine of 2.02 (IQR, 1.58-2.95) (Table II). Length of stay was 13 days (IQR, 7-16 days) with an intensive care unit stay of 4 days (IQR, 2-7 days). Two patients (14%) required reoperations in the immediate perioperative period, one for retroperitoneal hematoma and one for target vessel (superior mesenteric artery) occlusion. Postoperative ankle-brachial indices were increased from a median of 0.52 bilaterally in the preoperative period to >1 postoperatively. Eight patients (57%) had follow-up over 2 years after TEA, with five patients (36%) having follow-up over 3 years. Three major adverse cardiac events were reported at last follow-up. Just one patient reported persistent symptoms of chronic mesenteric ischemia at 11 years after TEA. Symptomatic CRA of the paravisceral aorta is a complex disease rarely encountered even at a high-volume quaternary referral center. These patients can be expected to experience short-term postoperative complications and require intensive care. Despite these challenges, trapdoor transaortic endarterectomy is a safe, effective procedure for CRA and most patients achieve dramatic symptomatic improvement with durable results.Table IGeneral operative characteristics (n = 14)VariablesMedian [IQR] or No. (%)Procedure types Trapdoor endarterectomy8 (57) Trapdoor endarterectomy with aortobifemoral bypass6 (43)Starting clamp position Supraceliac13 (93) Supramesenteric1 (7)Subsequent clamp position Infrarenal10 (71) None4 (29)Aortic closure Primary closure12 (86) Bovine patch angioplasty1 (7) Dacron patch angioplasty1 (7)Revascularized vessels Celiac3 (21)Eversion endarterectomy3 (100) Superior mesenteric artery5 (36)Eversion endarterectomy4 (80)Catheter embolectomy1 (20) Left renal5 (36)Eversion endarterectomy4 (80)Bypass graft1 (20) Right renal3 (21)Eversion endarterectomy3 (100) Bilateral renals3 (21)Eversion endarterectomy3 (100) IMA1 (7)Eversion endarterectomy1 (100)Cold renal perfusion8 (57)Estimated blood loss, mL1650 [1025-3750]Intraoperative transfusion, units2 [1-4]Cell saver13 (93) Volume transfused, mL563 [231-900]Suprarenal clamp time, minutes (n = 13)26 [20-30]Operative time, minutes341 [315-416]IQR, Interquartile range. Open table in a new tab Table IIPostoperative course, (n = 14)VariableMedian [IQR] or No. (%)Inpatient complications Anemia14 (100) Acute kidney injury8 (57)Creatinine (peak)2.02 [1.58-2.95]Dialysis1 (7) Cardiopulmonary complications5 (36) Reoperation2 (14)Retroperitoneal hematoma1 (7)Secondary intervention1 (7) Ileus2 (14) Colitis2 (14) Deep vein thrombosis1 (7) Myocardial infarction1 (7) Infection1 (7) Death1 (7)Intensive care unit admission14 (100) Length of stay, days4 [2-7]Total length of stay, days13 [7-16]Laboratory tests Blood urea nitrogen (preoperative)14 [10-16] Creatinine (preoperative)1.01 [0.91-1.31] Creatinine (discharge)1.06 [0.70-1.35]Hemodynamics Right ABI (preoperative), n = 100.52 [0.34-0.90] Left ABI (preoperative), n = 100.52 [0.38-0.81] Right ABI (postoperative op), n = 91.12 [1.06-1.16] Left ABI (postoperative), n = 91.10 [1.09-1.15]Readmission within 30 days3 (21)Duration of follow-up, years2 [0.5-3.0]Outpatient complications, time postoperative3 (21) Ureteral stricture, 2 months1 (7) Loss of primary patency, 18 months1 (7) New chronic mesenteric ischemia, 8 years1 (7)Amputation0 (0)Persistent symptomatology at last follow-up (n = 13)1 (7) Claudication or rest pain0 (0) Mesenteric angina1 (7)Major adverse cardiac events at last follow-up3 (21) Death2 (14) Myocardial infarction1 (7)IQR, Interquartile range. 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Cerebral collateral circulation as an independent predictor for in-stent restenosis after carotid artery stenting.

In-stent restenosis is a crucial problem after carotid artery stenting, but the exact predictors of in-stent restenosis remain unclear. We aimed to evaluate the effect of cerebral collateral circulation on in-stent restenosis after carotid artery stenting and to establish a clinical prediction model for in-stent restenosis. This retrospective case-control study enrolled 296 patients with severe carotid artery stenosis of C1 segment (≥70%) who underwent stent therapy from June 2015 to December 2018. Based on follow-up data, the patients were divided into the in-stent restenosis and no in-stent restenosis groups. The collateral circulation of the brain was graded according to the criteria of the American Society for Interventional and Therapy Neuroradiology/Society for Interventional Radiology (ASITN/SIR). Clinical data were collected, such as age, sex, traditional vascular risk factors, blood cell count, high-sensitivity C-reactive protein, uric acid, stenosis degree before stenting and residual stenosis rate, and medication after stenting. Binary logistic regression analysis was performed to identify potential predictors of in-stent restenosis, and a clinical prediction model for in-stent restenosis after carotid artery stenting was established. Binary logistic regression analysis showed that poor collateral circulation was an independent predictor of in-stent restenosis (P=0.003). We also found that a 1% increase in residual stenosis rate was associated with a 9% increase in the risk of in-stent restenosis (P=0.02). Ischemic stroke history (P=0.03), family history of ischemic stroke (P<0.001), in-stent restenosis history (P<0.001), and nonstandard medication after stenting (P=0.04) were predictors of in-stent restenosis. The risk of in-stent restenosis was lowest when the residual stenosis rate was 12.5% after carotid artery stenting. Furthermore, we used some significant parameters to construct a binary logistic regression prediction model for in-stent restenosis after carotid artery stenting in the form of a nomogram. Collateral circulation is an independent predictor of in-stent restenosis after successful carotid artery stenting, and the residual stenosis rate tends to be below 12.5% to reduce restenosis risk. The standard medication should be strictly carried out for patients after stenting to prevent in-stent restenosis.