1
|
Huang WQ, Lin Q, Tzeng CM. Leukoaraiosis: Epidemiology, Imaging, Risk Factors, and Management of Age-Related Cerebral White Matter Hyperintensities. J Stroke 2024; 26:131-163. [PMID: 38836265 PMCID: PMC11164597 DOI: 10.5853/jos.2023.02719] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2023] [Accepted: 01/15/2024] [Indexed: 06/06/2024] Open
Abstract
Leukoaraiosis (LA) manifests as cerebral white matter hyperintensities on T2-weighted magnetic resonance imaging scans and corresponds to white matter lesions or abnormalities in brain tissue. Clinically, it is generally detected in the early 40s and is highly prevalent globally in individuals aged >60 years. From the imaging perspective, LA can present as several heterogeneous forms, including punctate and patchy lesions in deep or subcortical white matter; lesions with periventricular caps, a pencil-thin lining, and smooth halo; as well as irregular lesions, which are not always benign. Given its potential of having deleterious effects on normal brain function and the resulting increase in public health burden, considerable effort has been focused on investigating the associations between various risk factors and LA risk, and developing its associated clinical interventions. However, study results have been inconsistent, most likely due to potential differences in study designs, neuroimaging methods, and sample sizes as well as the inherent neuroimaging heterogeneity and multi-factorial nature of LA. In this article, we provided an overview of LA and summarized the current knowledge regarding its epidemiology, neuroimaging classification, pathological characteristics, risk factors, and potential intervention strategies.
Collapse
Affiliation(s)
- Wen-Qing Huang
- Department of Central Laboratory, Shanghai Children's Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Qing Lin
- Department of Neurology, The First Affiliated Hospital of Xiamen University, School of Medicine, Xiamen University, Xiamen, Fujian, China
- Xiamen Clinical Research Center for Neurological Diseases, The First Affiliated Hospital of Xiamen University, School of Medicine, Xiamen University, Xiamen, Fujian, China
- Fujian Provincial Clinical Research Center for Brain Diseases, The First Affiliated Hospital of Xiamen University, School of Medicine, Xiamen University, Xiamen, Fujian, China
- The Third Clinical College, Fujian Medical University, Fuzhou, Fujian, China
| | - Chi-Meng Tzeng
- Translational Medicine Research Center, School of Pharmaceutical Sciences, Xiamen University, Xiamen, Fujian, China
| |
Collapse
|
2
|
Blair G, Appleton JP, Mhlanga I, Woodhouse LJ, Doubal F, Bath PM, Wardlaw JM. Design of trials in lacunar stroke and cerebral small vessel disease: review and experience with the LACunar Intervention Trial 2 (LACI-2). Stroke Vasc Neurol 2024:svn-2023-003022. [PMID: 38569894 DOI: 10.1136/svn-2023-003022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2023] [Accepted: 03/02/2024] [Indexed: 04/05/2024] Open
Abstract
Cerebral small vessel disease (cSVD) causes lacunar stroke (25% of ischaemic strokes), haemorrhage, dementia, physical frailty, or is 'covert', but has no specific treatment. Uncertainties about the design of clinical trials in cSVD, which patients to include or outcomes to assess, may have delayed progress. Based on experience in recent cSVD trials, we reviewed ways to facilitate future trials in patients with cSVD.We assessed the literature and the LACunar Intervention Trial 2 (LACI-2) for data to inform choice of Participant, Intervention, Comparator, Outcome, including clinical versus intermediary endpoints, potential interventions, effect of outcome on missing data, methods to aid retention and reduce data loss. We modelled risk of missing outcomes by baseline prognostic variables in LACI-2 using binary logistic regression.Imaging versus clinical outcomes led to larger proportions of missing data. We present reasons for and against broad versus narrow entry criteria. We identified numerous repurposable drugs with relevant modes of action to test in various cSVD subtypes. Cognitive impairment is the most common clinical outcome after lacunar ischaemic stroke but was missing more frequently than dependency, quality of life or vascular events in LACI-2. Assessing cognitive status using Diagnostic and Statistical Manual for Mental Disorders Fifth Edition can use cognitive data from multiple sources and may help reduce data losses.Trials in patients with all cSVD subtypes are urgently needed and should use broad entry criteria and clinical outcomes and focus on ways to maximise collection of cognitive outcomes to avoid missing data.
Collapse
Affiliation(s)
| | - Jason P Appleton
- Stroke Trials Unit, Division of Clinical Neuroscience, University of Nottingham, Nottingham, UK
- Stroke, Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - Iris Mhlanga
- Stroke Trials Unit, Division of Clinical Neuroscience, University of Nottingham, Nottingham, UK
| | - Lisa J Woodhouse
- Stroke Trials Unit, Division of Clinical Neuroscience, University of Nottingham, Nottingham, UK
| | | | - Philip M Bath
- Stroke Trials Unit, Division of Clinical Neuroscience, University of Nottingham, Nottingham, UK
| | | |
Collapse
|
3
|
Ip BYM, Ko H, Lam BYK, Au LWC, Lau AYL, Huang J, Kwok AJ, Leng X, Cai Y, Leung TWH, Mok VCT. Current and Future Treatments of Vascular Cognitive Impairment. Stroke 2024; 55:822-839. [PMID: 38527144 DOI: 10.1161/strokeaha.123.044174] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/27/2024]
Affiliation(s)
- Bonaventure Yiu Ming Ip
- Division of Neurology, Department of Medicine and Therapeutics (B.Y.M.I., H.K., B.Y.K.L., L.W.C.A., A.Y.L.L., J.H., A.J.K., X.L., C.Y., T.W.H.L., V.C.T.M.), Faculty of Medicine, The Chinese University of Hong Kong
- Li Ka Shing Institute of Health Sciences (B.Y.M.I., H.K., B.Y.K.L., L.W.C.A., J.H., A.J.K., X.L., C.Y., T.W.H.L., V.C.T.M.), Faculty of Medicine, The Chinese University of Hong Kong
- Margaret K. L. Cheung Research Centre for Management of Parkinsonism (B.Y.M.I., H.K., B.Y.K.L., L.W.C.A., J.H., A.J.K., C.Y., V.C.T.M.), Faculty of Medicine, The Chinese University of Hong Kong
- Lau Tat-Chuen Research Centre of Brain Degenerative Diseases in Chinese (B.Y.M.I., H.K., B.Y.K.L., L.W.C.A., A.Y.L.L., J.H., A.J.K., C.Y., V.C.T.M.), Faculty of Medicine, The Chinese University of Hong Kong
- Gerald Choa Neuroscience Institute, The Chinese University of Hong Kong (B.Y.M.I., H.K., B.Y.K.L., L.W.C.A., J.H., A.J.K., C.Y., V.C.T.M.)
- Kwok Tak Seng Centre for Stroke Research and Intervention, Hong Kong SAR, China (B.Y.M.I., X.L., T.W.H.L.)
| | - Ho Ko
- Division of Neurology, Department of Medicine and Therapeutics (B.Y.M.I., H.K., B.Y.K.L., L.W.C.A., A.Y.L.L., J.H., A.J.K., X.L., C.Y., T.W.H.L., V.C.T.M.), Faculty of Medicine, The Chinese University of Hong Kong
- Li Ka Shing Institute of Health Sciences (B.Y.M.I., H.K., B.Y.K.L., L.W.C.A., J.H., A.J.K., X.L., C.Y., T.W.H.L., V.C.T.M.), Faculty of Medicine, The Chinese University of Hong Kong
- Margaret K. L. Cheung Research Centre for Management of Parkinsonism (B.Y.M.I., H.K., B.Y.K.L., L.W.C.A., J.H., A.J.K., C.Y., V.C.T.M.), Faculty of Medicine, The Chinese University of Hong Kong
- Lau Tat-Chuen Research Centre of Brain Degenerative Diseases in Chinese (B.Y.M.I., H.K., B.Y.K.L., L.W.C.A., A.Y.L.L., J.H., A.J.K., C.Y., V.C.T.M.), Faculty of Medicine, The Chinese University of Hong Kong
- Gerald Choa Neuroscience Institute, The Chinese University of Hong Kong (B.Y.M.I., H.K., B.Y.K.L., L.W.C.A., J.H., A.J.K., C.Y., V.C.T.M.)
| | - Bonnie Yin Ka Lam
- Division of Neurology, Department of Medicine and Therapeutics (B.Y.M.I., H.K., B.Y.K.L., L.W.C.A., A.Y.L.L., J.H., A.J.K., X.L., C.Y., T.W.H.L., V.C.T.M.), Faculty of Medicine, The Chinese University of Hong Kong
- Li Ka Shing Institute of Health Sciences (B.Y.M.I., H.K., B.Y.K.L., L.W.C.A., J.H., A.J.K., X.L., C.Y., T.W.H.L., V.C.T.M.), Faculty of Medicine, The Chinese University of Hong Kong
- Margaret K. L. Cheung Research Centre for Management of Parkinsonism (B.Y.M.I., H.K., B.Y.K.L., L.W.C.A., J.H., A.J.K., C.Y., V.C.T.M.), Faculty of Medicine, The Chinese University of Hong Kong
- Lau Tat-Chuen Research Centre of Brain Degenerative Diseases in Chinese (B.Y.M.I., H.K., B.Y.K.L., L.W.C.A., A.Y.L.L., J.H., A.J.K., C.Y., V.C.T.M.), Faculty of Medicine, The Chinese University of Hong Kong
- Gerald Choa Neuroscience Institute, The Chinese University of Hong Kong (B.Y.M.I., H.K., B.Y.K.L., L.W.C.A., J.H., A.J.K., C.Y., V.C.T.M.)
| | - Lisa Wing Chi Au
- Division of Neurology, Department of Medicine and Therapeutics (B.Y.M.I., H.K., B.Y.K.L., L.W.C.A., A.Y.L.L., J.H., A.J.K., X.L., C.Y., T.W.H.L., V.C.T.M.), Faculty of Medicine, The Chinese University of Hong Kong
- Li Ka Shing Institute of Health Sciences (B.Y.M.I., H.K., B.Y.K.L., L.W.C.A., J.H., A.J.K., X.L., C.Y., T.W.H.L., V.C.T.M.), Faculty of Medicine, The Chinese University of Hong Kong
- Margaret K. L. Cheung Research Centre for Management of Parkinsonism (B.Y.M.I., H.K., B.Y.K.L., L.W.C.A., J.H., A.J.K., C.Y., V.C.T.M.), Faculty of Medicine, The Chinese University of Hong Kong
- Lau Tat-Chuen Research Centre of Brain Degenerative Diseases in Chinese (B.Y.M.I., H.K., B.Y.K.L., L.W.C.A., A.Y.L.L., J.H., A.J.K., C.Y., V.C.T.M.), Faculty of Medicine, The Chinese University of Hong Kong
- Gerald Choa Neuroscience Institute, The Chinese University of Hong Kong (B.Y.M.I., H.K., B.Y.K.L., L.W.C.A., J.H., A.J.K., C.Y., V.C.T.M.)
| | - Alexander Yuk Lun Lau
- Division of Neurology, Department of Medicine and Therapeutics (B.Y.M.I., H.K., B.Y.K.L., L.W.C.A., A.Y.L.L., J.H., A.J.K., X.L., C.Y., T.W.H.L., V.C.T.M.), Faculty of Medicine, The Chinese University of Hong Kong
- Margaret K. L. Cheung Research Centre for Management of Parkinsonism (B.Y.M.I., H.K., B.Y.K.L., L.W.C.A., J.H., A.J.K., C.Y., V.C.T.M.), Faculty of Medicine, The Chinese University of Hong Kong
- Lau Tat-Chuen Research Centre of Brain Degenerative Diseases in Chinese (B.Y.M.I., H.K., B.Y.K.L., L.W.C.A., A.Y.L.L., J.H., A.J.K., C.Y., V.C.T.M.), Faculty of Medicine, The Chinese University of Hong Kong
| | - Junzhe Huang
- Division of Neurology, Department of Medicine and Therapeutics (B.Y.M.I., H.K., B.Y.K.L., L.W.C.A., A.Y.L.L., J.H., A.J.K., X.L., C.Y., T.W.H.L., V.C.T.M.), Faculty of Medicine, The Chinese University of Hong Kong
- Li Ka Shing Institute of Health Sciences (B.Y.M.I., H.K., B.Y.K.L., L.W.C.A., J.H., A.J.K., X.L., C.Y., T.W.H.L., V.C.T.M.), Faculty of Medicine, The Chinese University of Hong Kong
- Margaret K. L. Cheung Research Centre for Management of Parkinsonism (B.Y.M.I., H.K., B.Y.K.L., L.W.C.A., J.H., A.J.K., C.Y., V.C.T.M.), Faculty of Medicine, The Chinese University of Hong Kong
- Lau Tat-Chuen Research Centre of Brain Degenerative Diseases in Chinese (B.Y.M.I., H.K., B.Y.K.L., L.W.C.A., A.Y.L.L., J.H., A.J.K., C.Y., V.C.T.M.), Faculty of Medicine, The Chinese University of Hong Kong
- Gerald Choa Neuroscience Institute, The Chinese University of Hong Kong (B.Y.M.I., H.K., B.Y.K.L., L.W.C.A., J.H., A.J.K., C.Y., V.C.T.M.)
| | - Andrew John Kwok
- Division of Neurology, Department of Medicine and Therapeutics (B.Y.M.I., H.K., B.Y.K.L., L.W.C.A., A.Y.L.L., J.H., A.J.K., X.L., C.Y., T.W.H.L., V.C.T.M.), Faculty of Medicine, The Chinese University of Hong Kong
- Li Ka Shing Institute of Health Sciences (B.Y.M.I., H.K., B.Y.K.L., L.W.C.A., J.H., A.J.K., X.L., C.Y., T.W.H.L., V.C.T.M.), Faculty of Medicine, The Chinese University of Hong Kong
- Lau Tat-Chuen Research Centre of Brain Degenerative Diseases in Chinese (B.Y.M.I., H.K., B.Y.K.L., L.W.C.A., A.Y.L.L., J.H., A.J.K., C.Y., V.C.T.M.), Faculty of Medicine, The Chinese University of Hong Kong
- Gerald Choa Neuroscience Institute, The Chinese University of Hong Kong (B.Y.M.I., H.K., B.Y.K.L., L.W.C.A., J.H., A.J.K., C.Y., V.C.T.M.)
| | - Xinyi Leng
- Division of Neurology, Department of Medicine and Therapeutics (B.Y.M.I., H.K., B.Y.K.L., L.W.C.A., A.Y.L.L., J.H., A.J.K., X.L., C.Y., T.W.H.L., V.C.T.M.), Faculty of Medicine, The Chinese University of Hong Kong
- Li Ka Shing Institute of Health Sciences (B.Y.M.I., H.K., B.Y.K.L., L.W.C.A., J.H., A.J.K., X.L., C.Y., T.W.H.L., V.C.T.M.), Faculty of Medicine, The Chinese University of Hong Kong
- Kwok Tak Seng Centre for Stroke Research and Intervention, Hong Kong SAR, China (B.Y.M.I., X.L., T.W.H.L.)
| | - Yuan Cai
- Division of Neurology, Department of Medicine and Therapeutics (B.Y.M.I., H.K., B.Y.K.L., L.W.C.A., A.Y.L.L., J.H., A.J.K., X.L., C.Y., T.W.H.L., V.C.T.M.), Faculty of Medicine, The Chinese University of Hong Kong
- Li Ka Shing Institute of Health Sciences (B.Y.M.I., H.K., B.Y.K.L., L.W.C.A., J.H., A.J.K., X.L., C.Y., T.W.H.L., V.C.T.M.), Faculty of Medicine, The Chinese University of Hong Kong
- Margaret K. L. Cheung Research Centre for Management of Parkinsonism (B.Y.M.I., H.K., B.Y.K.L., L.W.C.A., J.H., A.J.K., C.Y., V.C.T.M.), Faculty of Medicine, The Chinese University of Hong Kong
- Lau Tat-Chuen Research Centre of Brain Degenerative Diseases in Chinese (B.Y.M.I., H.K., B.Y.K.L., L.W.C.A., A.Y.L.L., J.H., A.J.K., C.Y., V.C.T.M.), Faculty of Medicine, The Chinese University of Hong Kong
- Gerald Choa Neuroscience Institute, The Chinese University of Hong Kong (B.Y.M.I., H.K., B.Y.K.L., L.W.C.A., J.H., A.J.K., C.Y., V.C.T.M.)
| | - Thomas Wai Hong Leung
- Division of Neurology, Department of Medicine and Therapeutics (B.Y.M.I., H.K., B.Y.K.L., L.W.C.A., A.Y.L.L., J.H., A.J.K., X.L., C.Y., T.W.H.L., V.C.T.M.), Faculty of Medicine, The Chinese University of Hong Kong
- Li Ka Shing Institute of Health Sciences (B.Y.M.I., H.K., B.Y.K.L., L.W.C.A., J.H., A.J.K., X.L., C.Y., T.W.H.L., V.C.T.M.), Faculty of Medicine, The Chinese University of Hong Kong
- Kwok Tak Seng Centre for Stroke Research and Intervention, Hong Kong SAR, China (B.Y.M.I., X.L., T.W.H.L.)
| | - Vincent Chung Tong Mok
- Division of Neurology, Department of Medicine and Therapeutics (B.Y.M.I., H.K., B.Y.K.L., L.W.C.A., A.Y.L.L., J.H., A.J.K., X.L., C.Y., T.W.H.L., V.C.T.M.), Faculty of Medicine, The Chinese University of Hong Kong
- Li Ka Shing Institute of Health Sciences (B.Y.M.I., H.K., B.Y.K.L., L.W.C.A., J.H., A.J.K., X.L., C.Y., T.W.H.L., V.C.T.M.), Faculty of Medicine, The Chinese University of Hong Kong
- Margaret K. L. Cheung Research Centre for Management of Parkinsonism (B.Y.M.I., H.K., B.Y.K.L., L.W.C.A., J.H., A.J.K., C.Y., V.C.T.M.), Faculty of Medicine, The Chinese University of Hong Kong
- Lau Tat-Chuen Research Centre of Brain Degenerative Diseases in Chinese (B.Y.M.I., H.K., B.Y.K.L., L.W.C.A., A.Y.L.L., J.H., A.J.K., C.Y., V.C.T.M.), Faculty of Medicine, The Chinese University of Hong Kong
- Gerald Choa Neuroscience Institute, The Chinese University of Hong Kong (B.Y.M.I., H.K., B.Y.K.L., L.W.C.A., J.H., A.J.K., C.Y., V.C.T.M.)
| |
Collapse
|
4
|
Bronstein AM, Kattah J. Vascular neuro-otology: vestibular transient ischemic attacks and chronic dizziness in the elderly. Curr Opin Neurol 2024; 37:59-65. [PMID: 38032270 PMCID: PMC10779463 DOI: 10.1097/wco.0000000000001229] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2023]
Abstract
PURPOSE OF REVIEW To explore the differential diagnosis of posterior fossa transient ischemic attacks (TIA) associated with vertigo and/or imbalance.To review the contribution of cerebral small vessel (SVD) disease to balance dysfunction and dizziness in the elderly. MAIN FINDINGS TIAs involving vestibular structures that mediate the vestibulo-ocular and vestibulospinal reflexes remain a diagnostic challenge because they overlap with causes of benign episodic vertigo. Here, we summarize the results of multidisciplinary specialty efforts to improve timely recognition and intervention of peripheral and central vestibular ischemia. More papers confirm that SVD is a major cause of gait disability, falls and cognitive disorder in the elderly. Recent work shows that early stages of SVD may also be responsible for dizziness in the elderly. The predominant location of the white matter changes, in the frontal deep white matter and genu of the corpus callosum, explains the association between cognitive and balance dysfunction in SVD related symptoms. SUMMARY The evaluation of patients with intermittent vascular vertigo represent a major diagnostic challenge, recent reviews explore the ideal design approach for a multidisciplinary study to increase early recognition and intervention. Hemispheric white matter microvascular ischemia has been the subject of research progress - advanced stages are known to cause gait disorder and dementia but early stages are associated with "idiopathic" dizziness in the elderly.
Collapse
Affiliation(s)
- Adolfo M. Bronstein
- Centre for Vestibular Neuroscience, Department of Brain Sciences, Imperial College London, Charing Cross Hospital, London, UK
| | - Jorge Kattah
- University of Illinois at Chicago | UIC Department of Neurology (Peoria), Chicago, Illinois, USA
| |
Collapse
|
5
|
Hainsworth AH, Markus HS, Schneider JA. Cerebral Small Vessel Disease, Hypertension, and Vascular Contributions to Cognitive Impairment and Dementia. Hypertension 2024; 81:75-86. [PMID: 38044814 PMCID: PMC10734789 DOI: 10.1161/hypertensionaha.123.19943] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/05/2023]
Abstract
Hypertension-associated cerebral small vessel disease is a common finding in older people. Strongly associated with age and hypertension, small vessel disease is found at autopsy in over 50% of people aged ≥65 years, with a spectrum of clinical manifestations. It is the main cause of lacunar stroke and a major source of vascular contributions to cognitive impairment and dementia. The brain areas affected are subcortical and periventricular white matter and deep gray nuclei. Neuropathological sequelae are diffuse white matter lesions (seen as white matter hyperintensities on T2-weighted magnetic resonance imaging), small ischemic foci (lacunes or microinfarcts), and less commonly, subcortical microhemorrhages. The most common form of cerebral small vessel disease is concentric, fibrotic thickening of small penetrating arteries (up to 300 microns outer diameter) termed arteriolosclerosis. Less common forms are small artery atheroma and lipohyalinosis (the lesions described by C. Miller Fisher adjacent to lacunes). Other microvascular lesions that are not reviewed here include cerebral amyloid angiopathy and venous collagenosis. Here, we review the epidemiology, neuropathology, clinical management, genetics, preclinical models, and pathogenesis of hypertensive small vessel disease. Knowledge gaps include initiating factors, molecular pathogenesis, relationships between arterial pathology and tissue damage, possible reversibility, pharmacological targets, and molecular biomarkers. Progress is anticipated from multicell transcriptomic and proteomic profiling, novel experimental models and further target-finding and interventional clinical studies.
Collapse
Affiliation(s)
- Atticus H. Hainsworth
- Molecular and Clinical Sciences Research Institute, St George’s University of London, United Kingdom (A.H.H.)
- Department of Neurology, St George’s University Hospitals NHS Foundation Trust, London, United Kingdom (A.H.H.)
| | - Hugh S. Markus
- Stroke Research Group, Department of Clinical Neurosciences, University of Cambridge, United Kingdom (H.S.M.)
| | - Julie A. Schneider
- Rush Alzheimer’s Disease Center, Departments of Pathology and Neurological Sciences, Rush University Medical Center, Chicago, IL (J.A.S.)
| |
Collapse
|
6
|
Kopczak A, Stringer MS, van den Brink H, Kerkhofs D, Blair GW, van Dinther M, Reyes CA, Garcia DJ, Onkenhout L, Wartolowska KA, Thrippleton MJ, Kampaite A, Duering M, Staals J, Lesnik-Oberstein S, Muir KW, Middeke M, Norrving B, Bousser MG, Mansmann U, Rothwell PM, Doubal FN, van Oostenbrugge R, Biessels GJ, Webb AJS, Wardlaw JM, Dichgans M. Effect of blood pressure-lowering agents on microvascular function in people with small vessel diseases (TREAT-SVDs): a multicentre, open-label, randomised, crossover trial. Lancet Neurol 2023; 22:991-1004. [PMID: 37863608 DOI: 10.1016/s1474-4422(23)00293-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2023] [Revised: 06/15/2023] [Accepted: 08/01/2023] [Indexed: 10/22/2023]
Abstract
BACKGROUND Hypertension is the leading risk factor for cerebral small vessel disease. We aimed to determine whether antihypertensive drug classes differentially affect microvascular function in people with small vessel disease. METHODS We did a multicentre, open-label, randomised crossover trial with blinded endpoint assessment at five specialist centres in Europe. We included participants aged 18 years or older with symptomatic sporadic small vessel disease or cerebral autosomal dominant arteriopathy with subcortical infarcts and leukoencephalopathy (CADASIL) and an indication for antihypertensive treatment. Participants were randomly assigned (1:1:1) to one of three sequences of antihypertensive treatment using a computer-generated multiblock randomisation, stratified by study site and patient group. A 2-week washout period was followed by three 4-week periods of oral monotherapy with amlodipine, losartan, or atenolol at approved doses. The primary endpoint was change in cerebrovascular reactivity (CVR) determined by blood oxygen level-dependent MRI response to hypercapnic challenge in normal-appearing white matter from the end of washout to the end of each treatment period. Efficacy analyses were done by intention-to-treat principles in all randomly assigned participants who had at least one valid assessment for the primary endpoint, and analyses were done separately for participants with sporadic small vessel disease and CADASIL. This trial is registered at ClinicalTrials.gov, NCT03082014, and EudraCT, 2016-002920-10, and is terminated. FINDINGS Between Feb 22, 2018, and April 28, 2022, 75 participants with sporadic small vessel disease (mean age 64·9 years [SD 9·9]) and 26 with CADASIL (53·1 years [7·0]) were enrolled and randomly assigned to treatment. 79 participants (62 with sporadic small vessel disease and 17 with CADASIL) entered the primary efficacy analysis. Change in CVR did not differ between study drugs in participants with sporadic small vessel disease (mean change in CVR 1·8 × 10-4%/mm Hg [SE 20·1; 95% CI -37·6 to 41·2] for amlodipine; 16·7 × 10-4%/mm Hg [20·0; -22·3 to 55·8] for losartan; -7·1 × 10-4%/mm Hg [19·6; -45·5 to 31·1] for atenolol; poverall=0·39) but did differ in patients with CADASIL (15·7 × 10-4%/mm Hg [SE 27·5; 95% CI -38·3 to 69·7] for amlodipine; 19·4 × 10-4%/mm Hg [27·9; -35·3 to 74·2] for losartan; -23·9 × 10-4%/mm Hg [27·5; -77·7 to 30·0] for atenolol; poverall=0·019). In patients with CADASIL, pairwise comparisons showed that CVR improved with amlodipine compared with atenolol (-39·6 × 10-4%/mm Hg [95% CI -72·5 to -6·6; p=0·019) and with losartan compared with atenolol (-43·3 × 10-4%/mm Hg [-74·3 to -12·3]; p=0·0061). No deaths occurred. Two serious adverse events were recorded, one while taking amlodipine (diarrhoea with dehydration) and one while taking atenolol (fall with fracture), neither of which was related to study drug intake. INTERPRETATION 4 weeks of treatment with amlodipine, losartan, or atenolol did not differ in their effects on cerebrovascular reactivity in people with sporadic small vessel disease but did result in differential treatment effects in patients with CADASIL. Whether antihypertensive drug classes differentially affect clinical outcomes in people with small vessel diseases requires further research. FUNDING EU Horizon 2020 programme.
Collapse
Affiliation(s)
- Anna Kopczak
- Institute for Stroke and Dementia Research, University Hospital, LMU Munich, Munich, Germany
| | - Michael S Stringer
- Centre for Clinical Brain Sciences, University of Edinburgh, Edinburgh, UK; UK Dementia Research Institute, University of Edinburgh, Edinburgh, UK
| | - Hilde van den Brink
- Department of Neurology, UMC Utrecht Brain Center, University Medical Center Utrecht, Utrecht, Netherlands
| | - Danielle Kerkhofs
- Department of Neurology and School for Cardiovascular Diseases, Maastricht University Medical Center+, Maastricht, Netherlands
| | - Gordon W Blair
- Centre for Clinical Brain Sciences, University of Edinburgh, Edinburgh, UK
| | - Maud van Dinther
- Department of Neurology and School for Cardiovascular Diseases, Maastricht University Medical Center+, Maastricht, Netherlands
| | - Carmen Arteaga Reyes
- Centre for Clinical Brain Sciences, University of Edinburgh, Edinburgh, UK; UK Dementia Research Institute, University of Edinburgh, Edinburgh, UK
| | - Daniela Jaime Garcia
- Centre for Clinical Brain Sciences, University of Edinburgh, Edinburgh, UK; UK Dementia Research Institute, University of Edinburgh, Edinburgh, UK
| | - Laurien Onkenhout
- Department of Neurology, UMC Utrecht Brain Center, University Medical Center Utrecht, Utrecht, Netherlands
| | - Karolina A Wartolowska
- Wolfson Centre for Prevention of Stroke and Dementia, Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, UK
| | - Michael J Thrippleton
- Centre for Clinical Brain Sciences, University of Edinburgh, Edinburgh, UK; UK Dementia Research Institute, University of Edinburgh, Edinburgh, UK
| | - Agniete Kampaite
- Centre for Clinical Brain Sciences, University of Edinburgh, Edinburgh, UK; UK Dementia Research Institute, University of Edinburgh, Edinburgh, UK
| | - Marco Duering
- Institute for Stroke and Dementia Research, University Hospital, LMU Munich, Munich, Germany; Medical Image Analysis Center and Department of Biomedical Engineering, University of Basel, Basel, Switzerland
| | - Julie Staals
- Department of Neurology and School for Cardiovascular Diseases, Maastricht University Medical Center+, Maastricht, Netherlands
| | | | - Keith W Muir
- School of Psychology and Neuroscience, University of Glasgow, Queen Elizabeth University Hospital, Glasgow, UK
| | - Martin Middeke
- Hypertoniezentrum München, Excellence Centre of the European Society of Hypertension, Munich, Germany
| | - Bo Norrving
- Department of Clinical Sciences Lund, Neurology, Skåne University Hospital, Lund University, Lund, Sweden
| | | | - Ulrich Mansmann
- Institute for Medical Information Processing, Biometry, and Epidemiology, LMU Munich, Munich, Germany
| | - Peter M Rothwell
- Wolfson Centre for Prevention of Stroke and Dementia, Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, UK
| | - Fergus N Doubal
- Centre for Clinical Brain Sciences, University of Edinburgh, Edinburgh, UK; UK Dementia Research Institute, University of Edinburgh, Edinburgh, UK
| | - Robert van Oostenbrugge
- Department of Neurology and School for Cardiovascular Diseases, Maastricht University Medical Center+, Maastricht, Netherlands
| | - Geert Jan Biessels
- Department of Neurology, UMC Utrecht Brain Center, University Medical Center Utrecht, Utrecht, Netherlands
| | - Alastair J S Webb
- Wolfson Centre for Prevention of Stroke and Dementia, Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, UK
| | - Joanna M Wardlaw
- Centre for Clinical Brain Sciences, University of Edinburgh, Edinburgh, UK; UK Dementia Research Institute, University of Edinburgh, Edinburgh, UK
| | - Martin Dichgans
- Institute for Stroke and Dementia Research, University Hospital, LMU Munich, Munich, Germany; Munich Cluster for Systems Neurology, Munich, Germany; German Center for Neurodegenerative Diseases, Munich, Germany; German Centre for Cardiovascular Research, Munich, Germany.
| |
Collapse
|
7
|
Wiersinga JHI, Rhodius-Meester HFM, Wolters FJ, Trappenburg MC, Lemstra AW, Barkhof F, Peters MJL, van der Flier WM, Muller M. Orthostatic hypotension and its association with cerebral small vessel disease in a memory clinic population. J Hypertens 2023; 41:1738-1744. [PMID: 37589676 DOI: 10.1097/hjh.0000000000003525] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/18/2023]
Abstract
BACKGROUND Orthostatic hypotension (OH), an impaired blood pressure (BP) response to postural change, has been associated with cognitive decline and dementia, possibly through cerebral small vessel disease (CSVD). We hypothesized that longer duration of BP drop and a larger BP drop is associated with increased risk of CSVD. METHODS This cross-sectional study included 3971 memory clinic patients (mean age 68 years, 45% female, 42% subjective cognitive complaints, 17% mild cognitive impairment, 41% dementia) from the Amsterdam Ageing Cohort and Amsterdam Dementia Cohort. Early OH (EOH) was defined as a drop in BP of ±20 mmHg systolic and/or 10 mmHg diastolic only at 1 min after standing, and delayed/prolonged OH (DPOH) at 1 and/or 3 min after standing. Presence of CSVD [white matter hyperintensities (WMH), lacunes, microbleeds] was assessed with MRI ( n = 3584) or CT brain (n = 389). RESULTS The prevalence of early OH was 9% and of delayed/prolonged OH 18%. Age- and sex-adjusted logistic regression analyses showed that delayed/prolonged OH, but not early OH, was significantly associated with a higher burden of WMH (OR, 95%CI: 1.21, 1.00-1.46) and lacunes (OR, 95%CI 1.34, 1.06-1.69), but not microbleeds (OR, 95%CI 1.22, 0.89-1.67). When adjusting for supine SBP, these associations attenuated (ORs, 95%CI for WMH 1.04, 0.85-1.27; for lacunes 1.21, 0.91-1.62; for microbleeds 0.95, 0.68-1.31). A larger drop in SBP was associated with increased risk of WMH and microbleeds, however, when adjusted for supine SBP, this effect diminished. CONCLUSIONS Among memory clinic patients, DPOH is more common than EOH. While longer duration and larger magnitude of BP drop coincided with a higher burden of CSVD, these associations were largely explained by high supine BP.
Collapse
Affiliation(s)
- Julia H I Wiersinga
- Amsterdam UMC location Vrije Universiteit Amsterdam, Department of Internal Medicine section Geriatrics
- Amsterdam Cardiovascular Sciences, Atherosclerosis & Ischemic Syndromes
| | - Hanneke F M Rhodius-Meester
- Amsterdam UMC location Vrije Universiteit Amsterdam, Department of Internal Medicine section Geriatrics
- Amsterdam UMC location Vrije Universiteit Amsterdam, Alzheimer Center Amsterdam & Department of Neurology, Amsterdam, The Netherlands
- Oslo University Hospital, Department of Geriatric Medicine, Ullevål, Oslo, Norway
| | - Frank J Wolters
- Erasmus Medical Center, Department of Epidemiology, Rotterdam
- Erasmus Medical Center, Departments of Radiology & Nuclear Medicine and Alzheimer Center Erasmus MC, Rotterdam, The Netherlands
| | - Marijke C Trappenburg
- Amsterdam UMC location Vrije Universiteit Amsterdam, Department of Internal Medicine section Geriatrics
- Amstelland Hospital, Department of Internal Medicine section Geriatrics, Amstelveen
- Amsterdam UMC location Vrije Universiteit Amsterdam, Department of Radiology, Amsterdam, The Netherlands
| | - Afina W Lemstra
- Amsterdam UMC location Vrije Universiteit Amsterdam, Alzheimer Center Amsterdam & Department of Neurology, Amsterdam, The Netherlands
| | - Frederik Barkhof
- Amsterdam UMC location Vrije Universiteit Amsterdam, Alzheimer Center Amsterdam & Department of Neurology, Amsterdam, The Netherlands
- Centre for Medical Image Computing, Department of Medical Physics and Biomedical Engineering, University College London, London, UK
- Amsterdam Neuroscience, Neurodegeneration, Brain Imaging, Amsterdam
| | - Mike J L Peters
- UMC Utrecht, University of Utrecht, Department of Internal Medicine section Geriatrics, Utrecht
| | - Wiesje M van der Flier
- Amsterdam UMC location Vrije Universiteit Amsterdam, Alzheimer Center Amsterdam & Department of Neurology, Amsterdam, The Netherlands
- Amsterdam Neuroscience, Neurodegeneration, Brain Imaging, Amsterdam
- Amsterdam UMC location Vrije Universiteit Amsterdam, Department of Epidemiology and Biostatistics, Amsterdam
| | - Majon Muller
- Amsterdam UMC location Vrije Universiteit Amsterdam, Department of Internal Medicine section Geriatrics
- Amsterdam Cardiovascular Sciences, Atherosclerosis & Ischemic Syndromes
| |
Collapse
|
8
|
Brown RB, Tozer DJ, Egle M, Tuladhar AM, de Leeuw FE, Markus HS. How often does white matter hyperintensity volume regress in cerebral small vessel disease? Int J Stroke 2023; 18:937-947. [PMID: 36988075 PMCID: PMC10507994 DOI: 10.1177/17474930231169132] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2022] [Accepted: 03/14/2023] [Indexed: 03/30/2023]
Abstract
BACKGROUND AND OBJECTIVES It has been suggested that white matter hyperintensity lesions (WMHs), which typically progress over time, can also regress, and that this might be associated with favorable cognitive performance. We determined the prevalence of WMH regression in patients with cerebral small vessel disease (SVD) and examined which demographic, clinical, and radiological markers were associated with this regression. METHODS We used semi-automated lesion marking methods to quantify WMH volume at multiple timepoints in three cohorts with symptomatic SVD; two with moderate-to-severe symptomatic SVD (the SCANS observational cohort and the control arm of the PRESERVE interventional trial) and one with mild-to-moderate SVD (the RUN DMC observational cohort). Mixed-effects ordered logistic regression models were used to test which factors predicted participants to show WMH regression. RESULTS No participants (0/98) in SCANS, 6/42 (14.3%) participants in PRESERVE, and 6/276 (2.2%) in RUN DMC showed WMH regression. On multivariate analysis, only lower WMH volume (OR: 0.36, 95% CI: 0.23-0.56) and better white matter microstructural integrity assessed by fractional anisotropy using diffusion tensor imaging (OR: 1.55, 95% CI: 1.07-2.24) predicted participant classification as regressor versus stable or progressor. DISCUSSION Only a small proportion of participants demonstrated WMH regression across the three cohorts, when a blinded standardized assessment method was used. Subjects who showed regression had less severe imaging markers of disease at baseline. Our results show that lesion regression is uncommon in SVD and unlikely to be a major factor affecting the use of WMH quantification as an outcome for clinical trials.
Collapse
Affiliation(s)
- Robin B Brown
- Department of Clinical Neurosciences, University of Cambridge, Cambridge, UK
| | - Daniel J Tozer
- Department of Clinical Neurosciences, University of Cambridge, Cambridge, UK
| | - Marco Egle
- Department of Clinical Neurosciences, University of Cambridge, Cambridge, UK
| | - Anil M Tuladhar
- Department of Neurology, Centre for Cognitive Neuroscience, Donders Institute for Brain, Cognition and Behaviour, Radboud University Medical Centre, Nijmegen, The Netherlands
| | - Frank-Erik de Leeuw
- Department of Neurology, Centre for Cognitive Neuroscience, Donders Institute for Brain, Cognition and Behaviour, Radboud University Medical Centre, Nijmegen, The Netherlands
| | - Hugh S Markus
- Department of Clinical Neurosciences, University of Cambridge, Cambridge, UK
| |
Collapse
|
9
|
Zhu X, Luo Z, Tian G, Hu Z, Li S, Wang QM, Luo X, Chen L. Hypotension and cognitive impairment among the elderly: Evidence from the CLHLS. PLoS One 2023; 18:e0291775. [PMID: 37725634 PMCID: PMC10508618 DOI: 10.1371/journal.pone.0291775] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2023] [Accepted: 08/25/2023] [Indexed: 09/21/2023] Open
Abstract
BACKGROUND While high blood pressure has been linked to cognitive impairment, the relationship between low blood pressure, especially hypotension, and cognitive impairment has not been well studied. Therefore, this study aimed to assess the prevalence of hypotension and cognitive impairment in the seniors of China, and the association between hypotension and cognitive function impairment. METHODS The data was derived from the 2018 wave of the Chinese Longitudinal Healthy Longevity Survey (CLHLS). Systolic blood pressures (SBP) and diastolic blood pressures (DBP) were measured by objective examination. The Chinese version of the Mini-Mental State Examination (CMMSE) was used to evaluate the cognitive impairment of the elderly. Generalized linear models were conducted to evaluate the association of hypotension with cognitive impairment. RESULTS The prevalence of hypotension and cognitive impairment in the Chinese elderly were 0.76% and 22.06%, respectively. Participants with hypotension, lower SBP, and lower DBP, had odds ratios of 1.62, 1.38, and 1.48 for cognitive impairment, respectively. Besides, the CMMSE scores decreased by 2.08, 0.86, and 1.08 in the elderly with hypotension, lower SBP, and DBP, compared with those with non-hypotension, higher SBP, and DBP, respectively. Subgroup analyses showed that the association of cognitive impairment with hypotension was stronger in Chinese elderly who had decreased activity of daily living. Moreover, there was statistical evidence of a nonlinear dose-response relationship of SBP and DBP with cognitive impairment (Pnonlinear < 0.05). CONCLUSION Hypotension was a potential risk factor for cognitive impairment of the Chinese elderly, especially for those having decreased activity of daily living. Blood pressure management should be conducted to prevent them from cognitive impairment.
Collapse
Affiliation(s)
- Xidi Zhu
- Department of Epidemiology and Health Statistics, Xiangya School of Public Health, Central South University, Changsha, China
- Stroke Biological Recovery Laboratory, Spaulding Rehabilitation Hospital, the Teaching Affiliate of Harvard Medical School, Boston, Massachusetts, United States of America
| | - Zhicheng Luo
- Department of Epidemiology and Health Statistics, Xiangya School of Public Health, Central South University, Changsha, China
| | - Gang Tian
- Department of Epidemiology and Health Statistics, Xiangya School of Public Health, Central South University, Changsha, China
| | - Zhao Hu
- Department of Social Medicine and Health Management, Xiangya School of Public Health, Central South University, Changsha, China
| | - Shaojie Li
- School of Public Health, Peking University, Beijing, China
| | - Qing Mei Wang
- Stroke Biological Recovery Laboratory, Spaulding Rehabilitation Hospital, the Teaching Affiliate of Harvard Medical School, Boston, Massachusetts, United States of America
| | - Xun Luo
- Kerry Rehabilitation Medicine Research Institute, Shenzhen, China
- School of Medicine, Shenzhen University, Shenzhen, China
| | - Lizhang Chen
- Department of Epidemiology and Health Statistics, Xiangya School of Public Health, Central South University, Changsha, China
| |
Collapse
|
10
|
Wu B, Liu F, Sun G, Wang S. Correlation between obstructive sleep apnea and cerebral small vessel disease: a mendelian randomization study. Genes Genomics 2023; 45:1179-1186. [PMID: 37300787 DOI: 10.1007/s13258-023-01402-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2023] [Accepted: 05/12/2023] [Indexed: 06/12/2023]
Abstract
BACKGROUND Whether obstructive sleep apnea (OSA) is causally associated with an increased risk of cerebral small vessel disease (CSVD) remains controversial. We conducted a two-sample Mendelian randomization (MR) study to clarify the causal relationship between OSA and CSVD risk. METHODS Single-nucleotide polymorphisms associated with OSA at the genome-wide significance level (P < 5 × 10- 8) in the FinnGen consortium were selected as instrumental variables. Summary-level data for white matter hyperintensities (WMHs), lacunar infarctions (LIs), cerebral microbleeds (CMBs), fractional anisotropy (FA), and mean diffusivity (MD) were obtained from three meta-analyses of genome-wide association studies (GWASs). The random-effects inverse-variance weighted (IVW) method was selected for the major analysis. Weighted-median, MR-Egger, MR pleiotropy residual sum and outlier (MR-PRESSO), and leave-one-out analysis methods were implemented for the sensitivity analyses. RESULTS Genetically predicted OSA was not associated with LIs (odds ratio [OR] = 1.10, 95% confidence interval [CI] = 0.86-1.40), WMHs (OR = 0.94, 95% CI = 0.83-1.07), FA (OR = 1.33, 95% CI = 0.75-2.33), MD (OR = 0.93, 95% CI = 0.58-1.47), CMBs (OR = 1.29, 95% CI = 0.86-1.94), mixed CMBs (OR = 1.17, 95% CI = 0.63-2.17), and lobar CMBs (OR = 1.15, 95% CI = 0.75-1.76) in IVW method. The results of the sensitivity analyses were generally consistent with the major analyses. CONCLUSIONS This MR study does not support causal associations between OSA and the risk of CSVD in individuals of European ancestry. These findings need to be further validated in randomized controlled trials, larger cohort studies, and MR studies based on larger GWASs.
Collapse
Affiliation(s)
- Bing Wu
- Department of Neurology, Army 78th Military Group Hospital, 1 Tian Qing Street, Ai Min District, Mudanjiang, 157000, China
| | - Fang Liu
- Department of Neurology, Army 78th Military Group Hospital, 1 Tian Qing Street, Ai Min District, Mudanjiang, 157000, China
| | - Guiyan Sun
- Department of Neurology, Army 78th Military Group Hospital, 1 Tian Qing Street, Ai Min District, Mudanjiang, 157000, China
| | - Shuang Wang
- Department of Neurology, Army 78th Military Group Hospital, 1 Tian Qing Street, Ai Min District, Mudanjiang, 157000, China.
| |
Collapse
|
11
|
Rashid T, Li K, Toledo JB, Nasrallah I, Pajewski NM, Dolui S, Detre J, Wolk DA, Liu H, Heckbert SR, Bryan RN, Williamson J, Davatzikos C, Seshadri S, Launer LJ, Habes M. Association of Intensive vs Standard Blood Pressure Control With Regional Changes in Cerebral Small Vessel Disease Biomarkers: Post Hoc Secondary Analysis of the SPRINT MIND Randomized Clinical Trial. JAMA Netw Open 2023; 6:e231055. [PMID: 36857053 PMCID: PMC9978954 DOI: 10.1001/jamanetworkopen.2023.1055] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/02/2023] Open
Abstract
IMPORTANCE Little is known about the associations of strict blood pressure (BP) control with microstructural changes in small vessel disease markers. OBJECTIVE To investigate the regional associations of intensive vs standard BP control with small vessel disease biomarkers, such as white matter lesions (WMLs), fractional anisotropy (FA), mean diffusivity (MD), and cerebral blood flow (CBF). DESIGN, SETTING, AND PARTICIPANTS The Systolic Blood Pressure Intervention Trial (SPRINT) is a multicenter randomized clinical trial that compared intensive systolic BP (SBP) control (SBP target <120 mm Hg) vs standard control (SBP target <140 mm Hg) among participants aged 50 years or older with hypertension and without diabetes or a history of stroke. The study began randomization on November 8, 2010, and stopped July 1, 2016, with a follow-up duration of approximately 4 years. A total of 670 and 458 participants completed brain magnetic resonance imaging at baseline and follow-up, respectively, and comprise the cohort for this post hoc analysis. Statistical analyses for this post hoc analysis were performed between August 2020 and October 2022. INTERVENTIONS At baseline, 355 participants received intensive SBP treatment and 315 participants received standard SBP treatment. MAIN OUTCOMES AND MEASURES The main outcomes were regional changes in WMLs, FA, MD (in white matter regions of interest), and CBF (in gray matter regions of interest). RESULTS At baseline, 355 participants (mean [SD] age, 67.7 [8.0] years; 200 men [56.3%]) received intensive BP treatment and 315 participants (mean [SD] age, 67.0 [8.4] years; 199 men [63.2%]) received standard BP treatment. Intensive treatment was associated with smaller mean increases in WML volume compared with standard treatment (644.5 mm3 vs 1258.1 mm3). The smaller mean increases were observed specifically in the deep white matter regions of the left anterior corona radiata (intensive treatment, 30.3 mm3 [95% CI, 16.0-44.5 mm3]; standard treatment, 80.5 mm3 [95% CI, 53.8-107.2 mm3]), left tapetum (intensive treatment, 11.8 mm3 [95% CI, 4.4-19.2 mm3]; standard treatment, 27.2 mm3 [95% CI, 19.4-35.0 mm3]), left superior fronto-occipital fasciculus (intensive treatment, 3.2 mm3 [95% CI, 0.7-5.8 mm3]; standard treatment, 9.4 mm3 [95% CI, 5.5-13.4 mm3]), left posterior corona radiata (intensive treatment, 26.0 mm3 [95% CI, 12.9-39.1 mm3]; standard treatment, 52.3 mm3 [95% CI, 34.8-69.8 mm3]), left splenium of the corpus callosum (intensive treatment, 45.4 mm3 [95% CI, 25.1-65.7 mm3]; standard treatment, 83.0 mm3 [95% CI, 58.7-107.2 mm3]), left posterior thalamic radiation (intensive treatment, 53.0 mm3 [95% CI, 29.8-76.2 mm3]; standard treatment, 106.9 mm3 [95% CI, 73.4-140.3 mm3]), and right posterior thalamic radiation (intensive treatment, 49.5 mm3 [95% CI, 24.3-74.7 mm3]; standard treatment, 102.6 mm3 [95% CI, 71.0-134.2 mm3]). CONCLUSIONS AND RELEVANCE This study suggests that intensive BP treatment, compared with standard treatment, was associated with a slower increase of WMLs, improved diffusion tensor imaging, and FA and CBF changes in several brain regions that represent vulnerable areas that may benefit from more strict BP control. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT01206062.
Collapse
Affiliation(s)
- Tanweer Rashid
- Neuroimage Analytics Laboratory and the Biggs Institute Neuroimaging Core, Glenn Biggs Institute for Alzheimer’s and Neurodegenerative Diseases, University of Texas Health Science Center San Antonio, San Antonio
| | - Karl Li
- Neuroimage Analytics Laboratory and the Biggs Institute Neuroimaging Core, Glenn Biggs Institute for Alzheimer’s and Neurodegenerative Diseases, University of Texas Health Science Center San Antonio, San Antonio
| | - Jon B. Toledo
- Department of Neurology, University of Florida, Gainesville
- Department of Neurology, Houston Methodist Hospital, Houston, Texas
| | - Ilya Nasrallah
- Department of Radiology, Hospital of the University of Pennsylvania, Philadelphia
- Center for Biomedical Image Computing and Analytics, University of Pennsylvania, Philadelphia
| | - Nicholas M. Pajewski
- Department of Biostatistics and Data Science, Wake Forest School of Medicine, Winston-Salem, North Carolina
| | - Sudipto Dolui
- Department of Radiology, Hospital of the University of Pennsylvania, Philadelphia
| | - John Detre
- Department of Radiology, Hospital of the University of Pennsylvania, Philadelphia
- Department of Neurology, University of Pennsylvania, Philadelphia
| | - David A. Wolk
- Department of Neurology, University of Pennsylvania, Philadelphia
| | - Hangfan Liu
- Center for Biomedical Image Computing and Analytics, University of Pennsylvania, Philadelphia
| | | | - R. Nick Bryan
- Department of Radiology, Hospital of the University of Pennsylvania, Philadelphia
| | - Jeff Williamson
- Section of Gerontology and Geriatric Medicine, Department of Internal Medicine, Wake Forest School of Medicine, Winston-Salem, North Carolina
| | - Christos Davatzikos
- Department of Radiology, Hospital of the University of Pennsylvania, Philadelphia
- Center for Biomedical Image Computing and Analytics, University of Pennsylvania, Philadelphia
| | - Sudha Seshadri
- Neuroimage Analytics Laboratory and the Biggs Institute Neuroimaging Core, Glenn Biggs Institute for Alzheimer’s and Neurodegenerative Diseases, University of Texas Health Science Center San Antonio, San Antonio
| | - Lenore J. Launer
- Intramural Research Program, Laboratory of Epidemiology and Population Sciences, National Institute on Aging, National Institutes of Health, Bethesda, Maryland
| | - Mohamad Habes
- Neuroimage Analytics Laboratory and the Biggs Institute Neuroimaging Core, Glenn Biggs Institute for Alzheimer’s and Neurodegenerative Diseases, University of Texas Health Science Center San Antonio, San Antonio
- Department of Radiology, Hospital of the University of Pennsylvania, Philadelphia
| |
Collapse
|
12
|
Kopczak A, Stringer MS, van den Brink H, Kerkhofs D, Blair GW, van Dinther M, Onkenhout L, Wartolowska KA, Thrippleton MJ, Duering M, Staals J, Middeke M, André E, Norrving B, Bousser MG, Mansmann U, Rothwell PM, Doubal FN, van Oostenbrugge R, Biessels GJ, Webb AJS, Wardlaw JM, Dichgans M. The EffecTs of Amlodipine and other Blood PREssure Lowering Agents on Microvascular FuncTion in Small Vessel Diseases (TREAT-SVDs) trial: Study protocol for a randomised crossover trial. Eur Stroke J 2023; 8:387-397. [PMID: 37021189 PMCID: PMC10069218 DOI: 10.1177/23969873221143570] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2022] [Accepted: 11/16/2022] [Indexed: 12/23/2022] Open
Abstract
Background Hypertension is the leading modifiable risk factor for cerebral small vessel diseases (SVDs). Yet, it is unknown whether antihypertensive drug classes differentially affect microvascular function in SVDs. Aims To test whether amlodipine has a beneficial effect on microvascular function when compared to either losartan or atenolol, and whether losartan has a beneficial effect when compared to atenolol in patients with symptomatic SVDs. Design TREAT-SVDs is an investigator-led, prospective, open-label, randomised crossover trial with blinded endpoint assessment (PROBE design) conducted at five study sites across Europe. Patients aged 18 years or older with symptomatic SVD who have an indication for antihypertensive treatment and are suffering from either sporadic SVD and a history of lacunar stroke or vascular cognitive impairment (group A) or CADASIL (group B) are randomly allocated 1:1:1 to one of three sequences of antihypertensive treatment. Patients stop their regular antihypertensive medication for a 2-week run-in period followed by 4-week periods of monotherapy with amlodipine, losartan and atenolol in random order as open-label medication in standard dose. Outcomes The primary outcome measure is cerebrovascular reactivity (CVR) as determined by blood oxygen level dependent brain MRI signal response to hypercapnic challenge with change in CVR in normal appearing white matter as primary endpoint. Secondary outcome measures are mean systolic blood pressure (BP) and BP variability (BPv). Discussion TREAT-SVDs will provide insights into the effects of different antihypertensive drugs on CVR, BP, and BPv in patients with symptomatic sporadic and hereditary SVDs. Funding European Union's Horizon 2020 programme. Trial registration NCT03082014.
Collapse
Affiliation(s)
- Anna Kopczak
- Institute for Stroke and Dementia
Research, University Hospital, LMU Munich, Munich, Germany
| | - Michael S Stringer
- Centre for Clinical Brain Sciences,
University of Edinburgh, Edinburgh, UK
| | - Hilde van den Brink
- Department of Neurology, UMC Utrecht
Brain Center, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Danielle Kerkhofs
- Department of Neurology and School for
cardiovascular diseases (CARIM), Maastricht University Medical Center+, Maastricht,
The Netherlands
| | - Gordon W Blair
- Centre for Clinical Brain Sciences,
University of Edinburgh, Edinburgh, UK
| | - Maud van Dinther
- Department of Neurology and School for
cardiovascular diseases (CARIM), Maastricht University Medical Center+, Maastricht,
The Netherlands
| | - Laurien Onkenhout
- Department of Neurology, UMC Utrecht
Brain Center, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Karolina A Wartolowska
- Wolfson Centre for Prevention of Stroke
and Dementia, Nuffield Department of Clinical Neurosciences, University of Oxford,
Oxford, UK
| | | | - Marco Duering
- Institute for Stroke and Dementia
Research, University Hospital, LMU Munich, Munich, Germany
- Medical Image Analysis Center (MIAC AG)
and Department of Biomedical Engineering, University of Basel, Basel,
Switzerland
| | - Julie Staals
- Department of Neurology and School for
cardiovascular diseases (CARIM), Maastricht University Medical Center+, Maastricht,
The Netherlands
| | - Martin Middeke
- Hypertoniezentrum München, Excellence
Centre of the European Society of Hypertension (ESH), Munich, Germany
| | - Elisabeth André
- Münchner Studienzentrum, Faculty of
Medicine, Technical University Munich (TUM), Munich, Germany
| | - Bo Norrving
- Neurology, Department of Clinical
Sciences Lund, Lund University, and Neurology, Skåne University Hospital Lund/Malmö,
Sweden
| | | | - Ulrich Mansmann
- Institute for Medical Information
Processing, Biometry, and Epidemiology, LMU Munich, Munich, Germany
| | - Peter M Rothwell
- Wolfson Centre for Prevention of Stroke
and Dementia, Nuffield Department of Clinical Neurosciences, University of Oxford,
Oxford, UK
| | - Fergus N Doubal
- Centre for Clinical Brain Sciences,
University of Edinburgh, Edinburgh, UK
| | - Robert van Oostenbrugge
- Department of Neurology and School for
cardiovascular diseases (CARIM), Maastricht University Medical Center+, Maastricht,
The Netherlands
| | - Geert Jan Biessels
- Department of Neurology, UMC Utrecht
Brain Center, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Alastair JS Webb
- Wolfson Centre for Prevention of Stroke
and Dementia, Nuffield Department of Clinical Neurosciences, University of Oxford,
Oxford, UK
| | - Joanna M Wardlaw
- Centre for Clinical Brain Sciences,
University of Edinburgh, Edinburgh, UK
- UK Dementia Research Institute,
University of Edinburgh, Edinburgh, UK
| | - Martin Dichgans
- Institute for Stroke and Dementia
Research, University Hospital, LMU Munich, Munich, Germany
- Munich Cluster for Systems Neurology
(SyNergy), Munich, Germany
- German Center for Neurodegenerative
Diseases (DZNE), Munich, Germany
| |
Collapse
|
13
|
Jiang C, Li S, Wang Y, Lai Y, Bai Y, Zhao M, He L, Kong Y, Guo X, Li S, Liu N, Jiang C, Tang R, Sang C, Long D, Du X, Dong J, Anderson CS, Ma C. Diastolic Blood Pressure and Intensive Blood Pressure Control on Cognitive Outcomes: Insights From the SPRINT MIND Trial. Hypertension 2023; 80:580-589. [PMID: 36688305 DOI: 10.1161/hypertensionaha.122.20112] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
Abstract
BACKGROUND The potential benefits or harms of intensive systolic blood pressure (BP) control on cognitive function and cerebral blood flow in individuals with low diastolic blood pressure (DBP) remain unclear. METHODS We conducted a post hoc analysis of the SPRINT MIND (Systolic Blood Pressure Intervention Trial Memory and Cognition in Decreased Hypertension) that randomly assigned hypertensive participants to an intensive (<120 mm Hg; n=4278) or standard (<140 mm Hg; n=4385) systolic blood pressure target. We evaluated the effects of BP intervention on cognitive outcomes and cerebral blood flow across baseline DBP quartiles. RESULTS Participants in the intensive group had a lower incidence rate of probable dementia or mild cognitive impairment than those in the standard group, regardless of DBP quartiles. The hazard ratio of intensive versus standard target for probable dementia or mild cognitive impairment was 0.91 (95% CI, 0.73-1.12) in the lowest DBP quartile and 0.70 (95% CI, 0.48-1.02) in the highest DBP quartile, respectively, with an interaction P value of 0.24. Similar results were found for probable dementia (interaction P=0.06) and mild cognitive impairment (interaction P=0.80). The effect of intensive treatment on cerebral blood flow was not modified by baseline DBP either (interaction P=0.25). Even among participants within the lowest DBP quartile, intensive versus standard BP treatment resulted in an increasing trend of annualized change in cerebral blood flow (+0.26 [95% CI, -0.72 to 1.24] mL/[100 g·min]). CONCLUSIONS Intensive BP control did not appear to have a detrimental effect on cognitive outcomes and cerebral perfusion in patients with low baseline DBP. REGISTRATION URL: https://www. CLINICALTRIALS gov; Unique identifier: NCT01206062.
Collapse
Affiliation(s)
- Chao Jiang
- Department of Cardiology, Beijing Anzhen Hospital, Capital Medical University and National Clinical Research Center for Cardiovascular Diseases, Beijing, China (C.J., S.L., Y.W., Y.L., M.Z., L.H., Y.K., X.G., S.L., N.L., C.J., R.T., C.S., D.L., X.D., J.D., C.M.)
| | - Sitong Li
- Department of Cardiology, Beijing Anzhen Hospital, Capital Medical University and National Clinical Research Center for Cardiovascular Diseases, Beijing, China (C.J., S.L., Y.W., Y.L., M.Z., L.H., Y.K., X.G., S.L., N.L., C.J., R.T., C.S., D.L., X.D., J.D., C.M.)
| | - Yufeng Wang
- Department of Cardiology, Beijing Anzhen Hospital, Capital Medical University and National Clinical Research Center for Cardiovascular Diseases, Beijing, China (C.J., S.L., Y.W., Y.L., M.Z., L.H., Y.K., X.G., S.L., N.L., C.J., R.T., C.S., D.L., X.D., J.D., C.M.)
| | - Yiwei Lai
- Department of Cardiology, Beijing Anzhen Hospital, Capital Medical University and National Clinical Research Center for Cardiovascular Diseases, Beijing, China (C.J., S.L., Y.W., Y.L., M.Z., L.H., Y.K., X.G., S.L., N.L., C.J., R.T., C.S., D.L., X.D., J.D., C.M.)
| | - Yu Bai
- DSchool of Clinical Medicine, Peking Union Medical College and Chinese Academy of Medical Science, Beijing, China (Y.B.)
| | - Manlin Zhao
- Department of Cardiology, Beijing Anzhen Hospital, Capital Medical University and National Clinical Research Center for Cardiovascular Diseases, Beijing, China (C.J., S.L., Y.W., Y.L., M.Z., L.H., Y.K., X.G., S.L., N.L., C.J., R.T., C.S., D.L., X.D., J.D., C.M.)
| | - Liu He
- Department of Cardiology, Beijing Anzhen Hospital, Capital Medical University and National Clinical Research Center for Cardiovascular Diseases, Beijing, China (C.J., S.L., Y.W., Y.L., M.Z., L.H., Y.K., X.G., S.L., N.L., C.J., R.T., C.S., D.L., X.D., J.D., C.M.)
| | - Yu Kong
- Department of Cardiology, Beijing Anzhen Hospital, Capital Medical University and National Clinical Research Center for Cardiovascular Diseases, Beijing, China (C.J., S.L., Y.W., Y.L., M.Z., L.H., Y.K., X.G., S.L., N.L., C.J., R.T., C.S., D.L., X.D., J.D., C.M.)
| | - Xueyuan Guo
- Department of Cardiology, Beijing Anzhen Hospital, Capital Medical University and National Clinical Research Center for Cardiovascular Diseases, Beijing, China (C.J., S.L., Y.W., Y.L., M.Z., L.H., Y.K., X.G., S.L., N.L., C.J., R.T., C.S., D.L., X.D., J.D., C.M.)
| | - Songnan Li
- Department of Cardiology, Beijing Anzhen Hospital, Capital Medical University and National Clinical Research Center for Cardiovascular Diseases, Beijing, China (C.J., S.L., Y.W., Y.L., M.Z., L.H., Y.K., X.G., S.L., N.L., C.J., R.T., C.S., D.L., X.D., J.D., C.M.)
| | - Nian Liu
- Department of Cardiology, Beijing Anzhen Hospital, Capital Medical University and National Clinical Research Center for Cardiovascular Diseases, Beijing, China (C.J., S.L., Y.W., Y.L., M.Z., L.H., Y.K., X.G., S.L., N.L., C.J., R.T., C.S., D.L., X.D., J.D., C.M.)
| | - Chenxi Jiang
- Department of Cardiology, Beijing Anzhen Hospital, Capital Medical University and National Clinical Research Center for Cardiovascular Diseases, Beijing, China (C.J., S.L., Y.W., Y.L., M.Z., L.H., Y.K., X.G., S.L., N.L., C.J., R.T., C.S., D.L., X.D., J.D., C.M.)
| | - Ribo Tang
- Department of Cardiology, Beijing Anzhen Hospital, Capital Medical University and National Clinical Research Center for Cardiovascular Diseases, Beijing, China (C.J., S.L., Y.W., Y.L., M.Z., L.H., Y.K., X.G., S.L., N.L., C.J., R.T., C.S., D.L., X.D., J.D., C.M.)
| | - Caihua Sang
- Department of Cardiology, Beijing Anzhen Hospital, Capital Medical University and National Clinical Research Center for Cardiovascular Diseases, Beijing, China (C.J., S.L., Y.W., Y.L., M.Z., L.H., Y.K., X.G., S.L., N.L., C.J., R.T., C.S., D.L., X.D., J.D., C.M.)
| | - Deyong Long
- Department of Cardiology, Beijing Anzhen Hospital, Capital Medical University and National Clinical Research Center for Cardiovascular Diseases, Beijing, China (C.J., S.L., Y.W., Y.L., M.Z., L.H., Y.K., X.G., S.L., N.L., C.J., R.T., C.S., D.L., X.D., J.D., C.M.)
| | - Xin Du
- Department of Cardiology, Beijing Anzhen Hospital, Capital Medical University and National Clinical Research Center for Cardiovascular Diseases, Beijing, China (C.J., S.L., Y.W., Y.L., M.Z., L.H., Y.K., X.G., S.L., N.L., C.J., R.T., C.S., D.L., X.D., J.D., C.M.).,DHeart Health Research Center, Beijing, China (X.D., C.S.A.)
| | - Jianzeng Dong
- Department of Cardiology, Beijing Anzhen Hospital, Capital Medical University and National Clinical Research Center for Cardiovascular Diseases, Beijing, China (C.J., S.L., Y.W., Y.L., M.Z., L.H., Y.K., X.G., S.L., N.L., C.J., R.T., C.S., D.L., X.D., J.D., C.M.).,DDepartment of Cardiology, The First Affiliated Hospital of Zhengzhou University, Henan Province, China (J.D.)
| | - Craig S Anderson
- DHeart Health Research Center, Beijing, China (X.D., C.S.A.).,DDepartment of Neurology, Royal Prince Alfred Hospital, University of Sydney, Australia (C.S.A.).,DFaculty of Medicine, The George Institute for Global Health, University of New South Wales, Sydney, Australia (C.S.A.)
| | - Changsheng Ma
- Department of Cardiology, Beijing Anzhen Hospital, Capital Medical University and National Clinical Research Center for Cardiovascular Diseases, Beijing, China (C.J., S.L., Y.W., Y.L., M.Z., L.H., Y.K., X.G., S.L., N.L., C.J., R.T., C.S., D.L., X.D., J.D., C.M.)
| |
Collapse
|
14
|
Chung CP, Ihara M, Hilal S, Chen LK. Targeting cerebral small vessel disease to promote healthy aging: Preserving physical and cognitive functions in the elderly. Arch Gerontol Geriatr 2023; 110:104982. [PMID: 36868073 DOI: 10.1016/j.archger.2023.104982] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2022] [Revised: 02/15/2023] [Accepted: 02/22/2023] [Indexed: 02/27/2023]
Abstract
Cerebral small vessel disease (SVD), which is highly age-related, is the most common neuroimaging finding in community-dwelling elderly individuals. In addition to increasing the risk of dementia and stroke, SVD is associated with cognitive and physical (particularly gait speed) functional impairments in the elderly. Here, we provide evidence suggesting covert SVD, e.g. without clinically evident stroke or dementia, as a critical target to preserve the functional ability that enables well-being in older age. First, we discuss the relationship between covert SVD and geriatric syndrome. SVD lesions found in non-demented, stroke-free elderly are actually not "silent" but are associated with accelerated age-related functional decline. We also review the brain structural and functional abnormalities associated with covert SVD and the possible mechanisms underlying their contributions to SVD-related cognitive and physical functional impairments. Finally, we reveal current data, though limited, on the management of elderly patients with covert SVD to prevent SVD lesion progression and functional decline. Although it is important in aging health, covert SVD is still under-recognized or misjudged by physicians in both neurological and geriatric professions. Improving the acknowledgment, detection, interpretation, and understanding of SVD would be a multidisciplinary priority to maintain cognitive and physical functions in the elderly. The dilemmas and future directions of clinical practice and research for the elderly with covert SVD are also included in the present review.
Collapse
Affiliation(s)
- Chih-Ping Chung
- Department of Neurology, Neurological Institute, Taipei Veterans General Hospital, Taipei, Taiwan; Center for Health Longevity and Aging Sciences, National Yang Ming Chiao Tung University College of Medicine, Taipei, Taiwan
| | - Masafumi Ihara
- Department of Neurology, National Cerebral and Cardiovascular Center, Osaka, Japan
| | - Saima Hilal
- Saw Swee Hock School of Public Health, National University of Singapore and National University Health System, Singapore; Memory Aging and Cognition Center, National University Health System, Singapore
| | - Liang-Kung Chen
- Center for Health Longevity and Aging Sciences, National Yang Ming Chiao Tung University College of Medicine, Taipei, Taiwan; Taipei Municipal Gan-Dau Hospital (managed by Taipei Veterans General Hospital), Taipei, Taiwan.
| |
Collapse
|
15
|
Gupta A, Boucher R, Wei G, Gronseth G, Parks A, Beddhu S. Influence of Baseline Diastolic Blood Pressure on the Effects of Systolic Blood Pressure Lowering on Cognitive Function in Type 2 Diabetes Mellitus. Am J Hypertens 2023; 36:120-125. [PMID: 36227718 PMCID: PMC9922945 DOI: 10.1093/ajh/hpac118] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2022] [Accepted: 10/12/2022] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Lowering of systolic blood pressure (SBP) in patients with low diastolic blood pressure (DBP), can further lower DBP. This can potentially decrease cerebral perfusion and cognition. We examined the influence of baseline DBP on the effect of lowering SBP on cognition. METHODS This is a post hoc analysis of the Memory in Diabetes (MIND) substudy (N = 1,430) of the Action to Control Cardiovascular Risk in Diabetes (ACCORD) study (NCT00000620). Standard neuropsychological tests (Digit Symbol Substitution Test [DSST], Mini-Mental State Examination [MMSE], Rey Auditory Verbal Learning Test [RAVLT], and Stroop test) were performed at baseline and months 20 and 40. We compared the effects of intensive (goal SBP <120 mm Hg) vs. standard (goal SBP <140 mm Hg) SBP control on the changes in the 4 test scores from baseline to the averages of months 20 and 40 across the range of baseline DBP using cubic spline terms. RESULTS Mean age was 63 ± 6 years, 55% were women and 66% White. Participates with lower baseline DBP were older, had more cardiovascular events and a longer duration of diabetes. There was no difference in the change in DSST (-0.22; 95% CI -0.97, 0.52), MMSE (-0.14; 95% CI -0.34, 0.06), RAVLT (-0.12; 95% CI -0.29, 0.06), and Stroop interference (-0.47; 95% CI -1.76, 0.82) in the intensive vs. standard SBP intervention. There was no interaction between baseline DBP and change in scores with the SBP intervention. CONCLUSIONS Intensive SBP reduction does not adversely affect cognition, even in those with low baseline DBP.
Collapse
Affiliation(s)
- Aditi Gupta
- Division of Nephrology and Hypertension, Department of Internal Medicine, University of Kansas Medical Center, Kansas City, Kansas, USA
- Department of Neurology, University of Kansas Medical Center, Kansas City, Kansas, USA
| | - Robert Boucher
- Division of Nephrology and Hypertension, Department of Internal Medicine, University of Utah, Salt Lake City, Utah, USA
| | - Guo Wei
- Division of Nephrology and Hypertension, Department of Internal Medicine, University of Utah, Salt Lake City, Utah, USA
| | - Gary Gronseth
- Department of Neurology, University of Kansas Medical Center, Kansas City, Kansas, USA
| | - Adam Parks
- Department of Neurology, University of Kansas Medical Center, Kansas City, Kansas, USA
- Department of Psychiatry and Behavioral Sciences, University of Kansas Medical Center, Kansas City, Kansas, USA
| | - Srinivasan Beddhu
- Division of Nephrology and Hypertension, Department of Internal Medicine, University of Utah, Salt Lake City, Utah, USA
| |
Collapse
|
16
|
Abstract
Cerebral small vessel disease (SVD) causes lacunar stroke and intracerebral hemorrhage, and is the most common pathology underlying vascular cognitive impairment. Increasingly, the importance of other clinical features of SVD is being recognized including motor impairment, (vascular) parkinsonism, impaired balance, falls, and behavioral symptoms, such as depression, apathy, and personality change. Epidemiological data show a high prevalence of the characteristic magnetic resonance imaging (MRI) features of white matter hyperintensities and lacunar infarcts in community studies, and recent data suggest that it is also a major health burden in low- and middle-income countries. In this review, we cover advances in diagnosis, imaging, clinical presentations, pathogenesis, and treatment.The two most common pathologies underlying SVD are arteriolosclerosis caused by aging, hypertension, and other conventional vascular risk factors, and cerebral amyloid angiopathy (CAA) caused by vascular deposition of β-amyloid. We discuss the revised Boston criteria of CAA based on MRI features, which have been recently validated. Imaging is providing important insights into pathogenesis, including improved detection of tissue damage using diffusion tensor imaging (DTI) leading to its use to monitor progression and surrogate endpoints in clinical trials. Advanced MRI techniques can demonstrate functional or dynamic abnormalities of the blood vessels, while the high spatial resolution provided by ultrahigh field MRI at 7 T allows imaging of individual perforating arteries for the first time, and the measurement of flow velocity and pulsatility within these arteries. DTI and structural network analysis have highlighted the importance of network disruption in mediating the effect of different SVD pathologies in causing a number of symptoms, including cognitive impairment, apathy, and gait disturbance.Despite the public health importance of SVD, there are few proven treatments. We review the evidence for primary prevention, and recent data showing how intensive blood pressure lowering reduces white matter hyperintensities (WMH) progression and delays the onset of cognitive impairment. There are few treatments for secondary prevention, but a number of trials are currently evaluating novel treatment approaches. Recent advances have implicated molecular processes related to endothelial dysfunction, nitric oxide synthesis, blood-brain barrier integrity, maintenance and repair of the extracellular matrix, and inflammation. Novel treatment approaches are being developed to a number of these targets. Finally, we highlight the importance of large International collaborative initiatives in SVD to address important research questions and cover a number which have recently been established.
Collapse
Affiliation(s)
- Hugh S Markus
- Stroke Research Group, Department of Clinical Neurosciences, University of Cambridge, Cambridge, UK
| | - Frank Erik de Leeuw
- Department of Neurology, Radboud University Medical Center, Nijmegen, The Netherlands.,Center for Medical Neuroscience, Donders Institute for Brain, Cognition and Behaviour, Nijmegen, The Netherlands
| |
Collapse
|
17
|
Pauls MMH, Binnie LR, Benjamin P, Betteridge S, Clarke B, Dhillon MPK, Ghatala R, Hainsworth FAH, Howe FA, Khan U, Kruuse C, Madigan JB, Moynihan B, Patel B, Pereira AC, Rostrup E, Shtaya ABY, Spilling CA, Trippier S, Williams R, Young R, Barrick TR, Isaacs JD, Hainsworth AH. The PASTIS trial: Testing tadalafil for possible use in vascular cognitive impairment. Alzheimers Dement 2022; 18:2393-2402. [PMID: 35135037 PMCID: PMC10078742 DOI: 10.1002/alz.12559] [Citation(s) in RCA: 16] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2021] [Revised: 10/13/2021] [Accepted: 12/07/2021] [Indexed: 01/31/2023]
Abstract
INTRODUCTION There are few randomized clinical trials in vascular cognitive impairment (VCI). This trial tested the hypothesis that the PDE5 inhibitor tadalafil, a widely used vasodilator, increases cerebral blood flow (CBF) in older people with symptomatic small vessel disease, the main cause of VCI. METHODS In a double-blind, placebo-controlled, cross-over trial, participants received tadalafil (20 mg) and placebo on two visits ≥7 days apart (randomized to order of treatment). The primary endpoint, change in subcortical CBF, was measured by arterial spin labelling. RESULTS Tadalafil increased CBF non-significantly in all subcortical areas (N = 55, age: 66.8 (8.6) years) with greatest treatment effect within white matter hyperintensities (+9.8%, P = .0960). There were incidental treatment effects on systolic and diastolic blood pressure (-7.8, -4.9 mmHg; P < .001). No serious adverse events were observed. DISCUSSION This trial did not identify a significant treatment effect of single-administration tadalafil on subcortical CBF. To detect treatment effects may require different dosing regimens.
Collapse
Affiliation(s)
- Mathilde M H Pauls
- Molecular & Clinical Sciences Research Institute, St George's University of London, London, UK.,Department of Neurology, St George's University Hospitals NHS Foundation Trust, London, UK
| | - Lauren R Binnie
- Molecular & Clinical Sciences Research Institute, St George's University of London, London, UK
| | - Philip Benjamin
- Molecular & Clinical Sciences Research Institute, St George's University of London, London, UK.,Department of Neuroradiology, St George's University Hospitals NHS Foundation Trust, London, UK
| | - Shai Betteridge
- Department of Neuropsychology, St George's University Hospitals NHS Foundation Trust, London, UK
| | - Brian Clarke
- Department of Neurology, St George's University Hospitals NHS Foundation Trust, London, UK
| | - Mohani-Preet K Dhillon
- Molecular & Clinical Sciences Research Institute, St George's University of London, London, UK
| | - Rita Ghatala
- South London Stroke Research Network, London, UK
| | - Fearghal A H Hainsworth
- Molecular & Clinical Sciences Research Institute, St George's University of London, London, UK
| | - Franklyn A Howe
- Molecular & Clinical Sciences Research Institute, St George's University of London, London, UK
| | - Usman Khan
- Department of Neurology, St George's University Hospitals NHS Foundation Trust, London, UK
| | - Christina Kruuse
- Department of Neurology and Neurovascular Research Unit, Herlev Gentofte Hospital, Hellerup, Denmark
| | - Jeremy B Madigan
- Department of Neuroradiology, St George's University Hospitals NHS Foundation Trust, London, UK
| | - Barry Moynihan
- Department of Neurology, St George's University Hospitals NHS Foundation Trust, London, UK.,Department of Medicine, Royal College of Surgeons in Ireland, Beaumont Hospital, Dublin, Ireland
| | - Bhavini Patel
- Department of Neurology, St George's University Hospitals NHS Foundation Trust, London, UK
| | - Anthony C Pereira
- Molecular & Clinical Sciences Research Institute, St George's University of London, London, UK.,Department of Neurology, St George's University Hospitals NHS Foundation Trust, London, UK
| | - Egill Rostrup
- Mental Health Centre, University of Copenhagen, Glostrup, Denmark
| | - Anan B Y Shtaya
- Molecular & Clinical Sciences Research Institute, St George's University of London, London, UK
| | - Catherine A Spilling
- Molecular & Clinical Sciences Research Institute, St George's University of London, London, UK
| | | | | | - Robin Young
- Robertson Centre for Biostatistics, University of Glasgow, Glasgow, UK
| | - Thomas R Barrick
- Molecular & Clinical Sciences Research Institute, St George's University of London, London, UK
| | - Jeremy D Isaacs
- Molecular & Clinical Sciences Research Institute, St George's University of London, London, UK.,Department of Neurology, St George's University Hospitals NHS Foundation Trust, London, UK
| | - Atticus H Hainsworth
- Molecular & Clinical Sciences Research Institute, St George's University of London, London, UK.,Department of Neurology, St George's University Hospitals NHS Foundation Trust, London, UK
| |
Collapse
|
18
|
Saiz LC, Gorricho J, Garjón J, Celaya MC, Erviti J, Leache L. Blood pressure targets for the treatment of people with hypertension and cardiovascular disease. Cochrane Database Syst Rev 2022; 11:CD010315. [PMID: 36398903 PMCID: PMC9673465 DOI: 10.1002/14651858.cd010315.pub5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
BACKGROUND This is the third update of the review first published in 2017. Hypertension is a prominent preventable cause of premature morbidity and mortality. People with hypertension and established cardiovascular disease are at particularly high risk, so reducing blood pressure to below standard targets may be beneficial. This strategy could reduce cardiovascular mortality and morbidity but could also increase adverse events. The optimal blood pressure target in people with hypertension and established cardiovascular disease remains unknown. OBJECTIVES To determine if lower blood pressure targets (systolic/diastolic 135/85 mmHg or less) are associated with reduction in mortality and morbidity compared with standard blood pressure targets (140 mmHg to 160mmHg/90 mmHg to 100 mmHg or less) in the treatment of people with hypertension and a history of cardiovascular disease (myocardial infarction, angina, stroke, peripheral vascular occlusive disease). SEARCH METHODS For this updated review, we used standard, extensive Cochrane search methods. The latest search date was January 2022. We applied no language restrictions. SELECTION CRITERIA We included randomized controlled trials (RCTs) with more than 50 participants per group that provided at least six months' follow-up. Trial reports had to present data for at least one primary outcome (total mortality, serious adverse events, total cardiovascular events, cardiovascular mortality). Eligible interventions involved lower targets for systolic/diastolic blood pressure (135/85 mmHg or less) compared with standard targets for blood pressure (140 mmHg to 160 mmHg/90 mmHg to 100 mmHg or less). Participants were adults with documented hypertension and adults receiving treatment for hypertension with a cardiovascular history for myocardial infarction, stroke, chronic peripheral vascular occlusive disease, or angina pectoris. DATA COLLECTION AND ANALYSIS We used standard Cochrane methods. We used GRADE to assess the certainty of the evidence. MAIN RESULTS We included seven RCTs that involved 9595 participants. Mean follow-up was 3.7 years (range 1.0 to 4.7 years). Six of seven RCTs provided individual participant data. None of the included studies was blinded to participants or clinicians because of the need to titrate antihypertensive drugs to reach a specific blood pressure goal. However, an independent committee blinded to group allocation assessed clinical events in all trials. Hence, we assessed all trials at high risk of performance bias and low risk of detection bias. We also considered other issues, such as early termination of studies and subgroups of participants not predefined, to downgrade the certainty of the evidence. We found there is probably little to no difference in total mortality (risk ratio (RR) 1.05, 95% confidence interval (CI) 0.91 to 1.23; 7 studies, 9595 participants; moderate-certainty evidence) or cardiovascular mortality (RR 1.03, 95% CI 0.82 to 1.29; 6 studies, 9484 participants; moderate-certainty evidence). Similarly, we found there may be little to no differences in serious adverse events (RR 1.01, 95% CI 0.94 to 1.08; 7 studies, 9595 participants; low-certainty evidence) or total cardiovascular events (including myocardial infarction, stroke, sudden death, hospitalization, or death from congestive heart failure (CHF)) (RR 0.89, 95% CI 0.80 to 1.00; 7 studies, 9595 participants; low-certainty evidence). The evidence was very uncertain about withdrawals due to adverse effects. However, studies suggest more participants may withdraw due to adverse effects in the lower target group (RR 8.16, 95% CI 2.06 to 32.28; 3 studies, 801 participants; very low-certainty evidence). Systolic and diastolic blood pressure readings were lower in the lower target group (systolic: mean difference (MD) -8.77 mmHg, 95% CI -12.82 to -4.73; 7 studies, 8657 participants; diastolic: MD -4.50 mmHg, 95% CI -6.35 to -2.65; 6 studies, 8546 participants). More drugs were needed in the lower target group (MD 0.56, 95% CI 0.16 to 0.96; 5 studies, 7910 participants), but blood pressure targets at one year were achieved more frequently in the standard target group (RR 1.20, 95% CI 1.17 to 1.23; 7 studies, 8699 participants). AUTHORS' CONCLUSIONS We found there is probably little to no difference in total mortality and cardiovascular mortality between people with hypertension and cardiovascular disease treated to a lower compared to a standard blood pressure target. There may also be little to no difference in serious adverse events or total cardiovascular events. This suggests that no net health benefit is derived from a lower systolic blood pressure target. We found very limited evidence on withdrawals due to adverse effects, which led to high uncertainty. At present, evidence is insufficient to justify lower blood pressure targets (135/85 mmHg or less) in people with hypertension and established cardiovascular disease. Several trials are still ongoing, which may provide an important input to this topic in the near future.
Collapse
Affiliation(s)
- Luis Carlos Saiz
- Unit of Innovation and Organization, Navarre Health Service, Pamplona, Spain
- Navarre Institute for Health Research (IdiSNA), Pamplona, Spain
| | - Javier Gorricho
- Navarre Institute for Health Research (IdiSNA), Pamplona, Spain
- Healthcare Business Intelligence Service, Navarre Health Service, Pamplona, Spain
| | - Javier Garjón
- Navarre Institute for Health Research (IdiSNA), Pamplona, Spain
- Medicines Advice and Information Service, Navarre Health Service, Pamplona, Spain
| | - Mª Concepción Celaya
- Navarre Institute for Health Research (IdiSNA), Pamplona, Spain
- Drug Prescribing Service, Navarre Health Service, Pamplona, Spain
| | - Juan Erviti
- Unit of Innovation and Organization, Navarre Health Service, Pamplona, Spain
- Navarre Institute for Health Research (IdiSNA), Pamplona, Spain
| | - Leire Leache
- Unit of Innovation and Organization, Navarre Health Service, Pamplona, Spain
- Navarre Institute for Health Research (IdiSNA), Pamplona, Spain
| |
Collapse
|
19
|
Markus HS, van Der Flier WM, Smith EE, Bath P, Biessels GJ, Briceno E, Brodtman A, Chabriat H, Chen C, de Leeuw FE, Egle M, Ganesh A, Georgakis MK, Gottesman RF, Kwon S, Launer L, Mok V, O'Brien J, Ottenhoff L, Pendlebury S, Richard E, Sachdev P, Schmidt R, Springer M, Tiedt S, Wardlaw JM, Verdelho A, Webb A, Werring D, Duering M, Levine D, Dichgans M. Framework for Clinical Trials in Cerebral Small Vessel Disease (FINESSE): A Review. JAMA Neurol 2022; 79:1187-1198. [PMID: 35969390 PMCID: PMC11036410 DOI: 10.1001/jamaneurol.2022.2262] [Citation(s) in RCA: 22] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
Importance Cerebral small vessel disease (SVD) causes a quarter of strokes and is the most common pathology underlying vascular cognitive impairment and dementia. An important step to developing new treatments is better trial methodology. Disease mechanisms in SVD differ from other stroke etiologies; therefore, treatments need to be evaluated in cohorts in which SVD has been well characterized. Furthermore, SVD itself can be caused by a number of different pathologies, the most common of which are arteriosclerosis and cerebral amyloid angiopathy. To date, there have been few sufficiently powered high-quality randomized clinical trials in SVD, and inconsistent trial methodology has made interpretation of some findings difficult. Observations To address these issues and develop guidelines for optimizing design of clinical trials in SVD, the Framework for Clinical Trials in Cerebral Small Vessel Disease (FINESSE) was created under the auspices of the International Society of Vascular Behavioral and Cognitive Disorders. Experts in relevant aspects of SVD trial methodology were convened, and a structured Delphi consensus process was used to develop recommendations. Areas in which recommendations were developed included optimal choice of study populations, choice of clinical end points, use of brain imaging as a surrogate outcome measure, use of circulating biomarkers for participant selection and as surrogate markers, novel trial designs, and prioritization of therapeutic agents using genetic data via Mendelian randomization. Conclusions and Relevance The FINESSE provides recommendations for trial design in SVD for which there are currently few effective treatments. However, new insights into understanding disease pathogenesis, particularly from recent genetic studies, provide novel pathways that could be therapeutically targeted. In addition, whether other currently available cardiovascular interventions are specifically effective in SVD, as opposed to other subtypes of stroke, remains uncertain. FINESSE provides a framework for design of trials examining such therapeutic approaches.
Collapse
Affiliation(s)
- Hugh S Markus
- Alzheimer Center Amsterdam, Department of Neurology, Epidemiology and Data Science, Amsterdam Neuroscience, Vrije Universiteit Amsterdam, Amsterdam UMC, Amsterdam, the Netherlands
| | - Wiesje M van Der Flier
- Alzheimer Center Amsterdam, Department of Neurology, Epidemiology and Data Science, Amsterdam Neuroscience, Vrije Universiteit Amsterdam, Amsterdam UMC, Amsterdam, the Netherlands
| | - Eric E Smith
- Department of Clinical Neurosciences and Hotchkiss Brain Institute, University of Calgary, Calgary, Alberta, Canada
| | - Philip Bath
- Stroke Trials Unit, Mental Health & Clinical Neuroscience, University of Nottingham, Nottingham, United Kingdom
| | - Geert Jan Biessels
- Department of Neurology, UMC Utrecht Brain Center, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Emily Briceno
- Department of Physical Medicine & Rehabilitation, University of Michigan Medical School, Ann Arbor
| | - Amy Brodtman
- Florey Institute of Neuroscience and Mental Health, Melbourne, Victoria, Australia
- University of Melbourne, Melbourne, Victoria, Australia
- Monash University, Melbourne, Victoria, Australia
| | - Hugues Chabriat
- Department of Neurology, FHU NeuroVasc, APHP, University of Paris, Paris, France
| | - Christopher Chen
- Memory Aging and Cognition Centre, Departments of Pharmacology and Psychological Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Frank-Erik de Leeuw
- Department of Neurology, Donders Institute for Brain, Cognition and Behaviour, Radboud University Medical Centre, Nijimegen, the Netherlands
| | - Marco Egle
- Department of Clinical Neurosciences, University of Cambridge, Cambridge, United Kingdom
| | - Aravind Ganesh
- Department of Clinical Neurosciences and Hotchkiss Brain Institute, University of Calgary, Calgary, Alberta, Canada
| | - Marios K Georgakis
- Institute for Stroke and Dementia Research (ISD), LMU University Hospital, Munich, Germany
- Center for Genomic Medicine, Massachusetts General Hospital, Harvard Medical School, Boston
- Munich Cluster for Systems Neurology (SyNergy), Munich, Germany
| | - Rebecca F Gottesman
- Now with National Institute of Neurological Disorders and Stroke Intramural Research Program, Bethesda, Maryland
- Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Sun Kwon
- University of Ulsan College of Medicine, Asan Medical Center, Seoul, Korea
| | - Lenore Launer
- Intramural Research Program, National Institute on Aging, Baltimore, Maryland
| | - Vincent Mok
- Gerald Choa Neuroscience Centre, Lui Che Woo Institute of Innovative Medicine, Margaret K.L. Cheung Research Centre for Management of Parkinsonism, Division of Neurology, Department of Medicine and Therapeutics, Faculty of Medicine, The Chinese University of Hong Kong, Hong Kong, China
| | - John O'Brien
- Department of Psychiatry, University of Cambridge, Cambridge, United Kingdom
| | - Lois Ottenhoff
- Alzheimer Center Amsterdam, Department of Neurology, Amsterdam Neuroscience, Vrije Universiteit Amsterdam and the Netherlands and Brain Research Center Amsterdam, the Netherlands
| | - Sarah Pendlebury
- Wolfson Centre for Prevention of Stroke and Dementia, Nuffield Department of Clinical Neurosciences, University of Oxford, NIHR Oxford Biomedical Research Centre, Departments of General (internal) Medicine and Geratology, Oxford University Hospitals NHS Foundation Trust, Oxford, United Kingdom
| | - Edo Richard
- Department of Neurology, Donders Institute for Brain, Cognition and Behaviour, Radboud University Medical Centre, Nijimegen, the Netherlands
| | - Perminder Sachdev
- Centre for Healthy Brain Ageing (CHeBA), University of New South Wales, Sydney, New South Wales, Australia
| | - Reinhold Schmidt
- Department of Neurology, Clinical Division of Neurogeriatrics, Medical University Graz, Graz, Austria
| | | | - Stefan Tiedt
- Institute for Stroke and Dementia Research (ISD), LMU University Hospital, Munich, Germany
- Munich Cluster for Systems Neurology (SyNergy), Munich, Germany
| | - Joanna M Wardlaw
- Centre for Clinical Brain Sciences, UK Dementia Research Institute Centre at the University of Edinburgh, Edinburgh, United Kingdom
| | - Ana Verdelho
- Faculdade de Medicina, Department of Neurosciences and Mental Health, CHULN-Hospital de Santa Maria Instituto de Medicina Molecular (IMM) e Instituto de Saúde Ambiental (ISAMB), University of Lisbon, Lisbon, Portugal
| | - Alastair Webb
- Wolfson Centre for Prevention of Stroke and Dementia, Department of Clinical Neurosciences, University of Oxford, Oxford, United Kingdom
| | - David Werring
- Stroke Research Centre, Department of Brain Repair and Rehabilitation, UCL Queen Square Institute of Neurology and the National Hospital for Neurology and Neurosurgery, London, United Kingdom
| | - Marco Duering
- Institute for Stroke and Dementia Research (ISD), LMU University Hospital, Munich, Germany
- Munich Cluster for Systems Neurology (SyNergy), Munich, Germany
- Medical Image Analysis Center (MIAC AG) and Quantitative Biomedical Imaging Group, Department of Biomedical Engineering, University of Basel, Basel, Switzerland
| | - Deborah Levine
- Departments of Internal Medicine and Neurology, University of Michigan, Ann Arbor
| | - Martin Dichgans
- Institute for Stroke and Dementia Research (ISD), LMU University Hospital, Munich, Germany
- Munich Cluster for Systems Neurology (SyNergy), Munich, Germany
| |
Collapse
|
20
|
Paschoal AM, Secchinatto KF, da Silva PHR, Zotin MCZ, Dos Santos AC, Viswanathan A, Pontes-Neto OM, Leoni RF. Contrast-agent-free state-of-the-art MRI on cerebral small vessel disease-part 1. ASL, IVIM, and CVR. NMR IN BIOMEDICINE 2022; 35:e4742. [PMID: 35429194 DOI: 10.1002/nbm.4742] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/14/2021] [Revised: 04/05/2022] [Accepted: 04/11/2022] [Indexed: 06/14/2023]
Abstract
Cerebral small vessel disease (cSVD), a common cause of stroke and dementia, is traditionally considered the small vessel equivalent of large artery occlusion or rupture that leads to cortical and subcortical brain damage. Microvessel endothelial dysfunction can also contribute to it. Brain imaging, including MRI, is useful to show the presence of lesions of several types, although the association between conventional MRI measures and clinical features of cSVD is not always concordant. We assessed the additional contribution of contrast-agent-free, state-of-the-art MRI techniques such as arterial spin labeling (ASL), diffusion tensor imaging, functional MRI, and intravoxel incoherent motion (IVIM) applied to cSVD in the existing literature. We performed a review following the PICO Worksheet and Search Strategy, including original papers in English, published between 2000 and 2022. For each MRI method, we extracted information about their contributions, in addition to those established with traditional MRI methods and related information about the origins, pathology, markers, and clinical outcomes in cSVD. This paper presents the first part of the review, which includes 37 studies focusing on ASL, IVIM, and cerebrovascular reactivity (CVR) measures. In general, they have shown that, in addition to white matter hyperintensities, alterations in other neuroimaging parameters such as blood flow and CVR also indicate the presence of cSVD. Such quantitative parameters were also related to cSVD risk factors. Therefore, they are promising, noninvasive tools to explore questions that have not yet been clarified about this clinical condition. However, protocol standardization is essential to increase their clinical use.
Collapse
Affiliation(s)
- André Monteiro Paschoal
- Department of Physics, FFCLRP, University of São Paulo, Ribeirão Preto, São Paulo, Brazil
- Department of Medical Imaging, Hematology and Clinical Oncology, Ribeirão Preto Medical School, University of São Paulo, Ribeirão Preto, São Paulo, Brazil
| | | | | | - Maria Clara Zanon Zotin
- Department of Medical Imaging, Hematology and Clinical Oncology, Ribeirão Preto Medical School, University of São Paulo, Ribeirão Preto, São Paulo, Brazil
- J. Philip Kistler Stroke Research Center, Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Antônio Carlos Dos Santos
- Department of Medical Imaging, Hematology and Clinical Oncology, Ribeirão Preto Medical School, University of São Paulo, Ribeirão Preto, São Paulo, Brazil
| | - Anand Viswanathan
- J. Philip Kistler Stroke Research Center, Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Octavio M Pontes-Neto
- Department of Neurosciences and Behavioral Science, Ribeirão Preto Medical School, University of Sao Paulo, Ribeirão Preto, São Paulo, Brazil
| | - Renata Ferranti Leoni
- Department of Physics, FFCLRP, University of São Paulo, Ribeirão Preto, São Paulo, Brazil
| |
Collapse
|
21
|
Song Q, Li J, Jiang Z. Provisional Decision-Making for Perioperative Blood Pressure Management: A Narrative Review. OXIDATIVE MEDICINE AND CELLULAR LONGEVITY 2022; 2022:5916040. [PMID: 35860431 PMCID: PMC9293529 DOI: 10.1155/2022/5916040] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/24/2022] [Revised: 06/21/2022] [Accepted: 06/24/2022] [Indexed: 11/21/2022]
Abstract
Blood pressure (BP) is a basic determinant for organ blood flow supply. Insufficient blood supply will cause tissue hypoxia, provoke cellular oxidative stress, and to some extent lead to organ injury. Perioperative BP is labile and dynamic, and intraoperative hypotension is common. It is unclear whether there is a causal relationship between intraoperative hypotension and organ injury. However, hypotension surely compromises perfusion and causes harm to some extent. Because the harm threshold remains unknown, various guidelines for intraoperative BP management have been proposed. With the pending definitions from robust randomized trials, it is reasonable to consider observational analyses suggesting that mean arterial pressures below 65 mmHg sustained for more than 15 minutes are associated with myocardial and renal injury. Advances in machine learning and artificial intelligence may facilitate the management of hemodynamics globally, including fluid administration, rather than BP alone. The previous mounting studies concentrated on associations between BP targets and adverse complications, whereas few studies were concerned about how to treat and multiple factors for decision-making. Hence, in this narrative review, we discussed the way of BP measurement and current knowledge about baseline BP extracting for surgical patients, highlighted the decision-making process for BP management with a view to providing pragmatic guidance for BP treatment in the clinical settings, and evaluated the merits of an automated blood control system in predicting hypotension.
Collapse
Affiliation(s)
- Qiliang Song
- Department of Anesthesiology, Shaoxing People's Hospital (Shaoxing Hospital, Zhejiang University School of Medicine), Shaoxing, 312000 Zhejiang Province, China
| | - Jipeng Li
- Department of Anesthesiology, Shaoxing People's Hospital (Shaoxing Hospital, Zhejiang University School of Medicine), Shaoxing, 312000 Zhejiang Province, China
| | - Zongming Jiang
- Department of Anesthesiology, Shaoxing People's Hospital (Shaoxing Hospital, Zhejiang University School of Medicine), Shaoxing, 312000 Zhejiang Province, China
| |
Collapse
|
22
|
Chi NF, Chung CP, Cheng HM, Liu CH, Lin CJ, Hsu LC, Tang SC, Lee JT, Po HL, Jeng JS, Wang TD, Lee IH. 2021 Taiwan Stroke Society Guidelines of blood pressure control for ischemic stroke prevention. J Chin Med Assoc 2022; 85:651-664. [PMID: 35507097 DOI: 10.1097/jcma.0000000000000738] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
BACKGROUND Since the publication of the 2015 Taiwan Stroke Society Blood Pressure for Treatment and Prevention of Stroke Guideline (2015 TSS BP Guideline), several new clinical studies have addressed whether a stricter blood pressure (BP) target would be effective for stroke prevention. METHODS TSS guideline consensus group provides recommendations on BP targets for stroke prevention based on updated evidences. RESULTS The present guideline covers five topics: (1) diagnosis of hypertension; (2) BP control and primary prevention of ischemic stroke; (3) BP control and secondary prevention of ischemic stroke; (4) BP control and secondary prevention of large artery atherosclerosis ischemic stroke; and (5) BP control and secondary prevention of small vessel occlusion ischemic stroke. CONCLUSION The BP target for most stroke patients with hypertension is <130/80 mm Hg.
Collapse
Affiliation(s)
- Nai-Fang Chi
- Department of Neurology, Neurological Institute, Taipei Veterans General Hospital, Taipei, Taiwan, ROC
- Department of Neurology in School of Medicine, National Yang Ming Chiao Tung University College of Medicine, Taipei, Taiwan, ROC
| | - Chih-Ping Chung
- Department of Neurology, Neurological Institute, Taipei Veterans General Hospital, Taipei, Taiwan, ROC
- Department of Neurology in School of Medicine, National Yang Ming Chiao Tung University College of Medicine, Taipei, Taiwan, ROC
| | - Hao-Ming Cheng
- Center for Evidence-based Medicine & Division of Cardiology, Taipei Veterans General Hospital, Taipei, Taiwan, ROC
- Department of Medicine, National Yang Ming Chiao Tung University College of Medicine, Taipei, Taiwan, ROC
- Institute of Public Health, National Yang Ming Chiao Tung University College of Medicine, Taipei, Taiwan, ROC
| | - Chi-Hung Liu
- Department of Neurology, Linkou Chang Gung Memorial Hospital, Taoyuan City, Taiwan, ROC
| | - Chun-Jen Lin
- Department of Neurology, Neurological Institute, Taipei Veterans General Hospital, Taipei, Taiwan, ROC
- Department of Neurology in School of Medicine, National Yang Ming Chiao Tung University College of Medicine, Taipei, Taiwan, ROC
| | - Li-Chi Hsu
- Department of Neurology, Neurological Institute, Taipei Veterans General Hospital, Taipei, Taiwan, ROC
- Department of Neurology in School of Medicine, National Yang Ming Chiao Tung University College of Medicine, Taipei, Taiwan, ROC
| | - Sung-Chun Tang
- Department of Neurology, National Taiwan University Hospital, Taipei, Taiwan, ROC
| | - Jiunn-Tay Lee
- Department of Neurology, Tri-Service General Hospital, Taipei, Taiwan, ROC
| | - Helen L Po
- Department of Neurology, Mackay Memorial Hospital, Taipei, Taiwan, ROC
| | - Jiann-Shing Jeng
- Department of Neurology, National Taiwan University Hospital, Taipei, Taiwan, ROC
| | - Tzung-Dau Wang
- Department of Cardiology, National Taiwan University, Taipei, Taiwan, ROC
| | - I-Hui Lee
- Department of Neurology, Neurological Institute, Taipei Veterans General Hospital, Taipei, Taiwan, ROC
- Department of Neurology in School of Medicine, National Yang Ming Chiao Tung University College of Medicine, Taipei, Taiwan, ROC
| |
Collapse
|
23
|
Daily blood pressure profile and blood-brain barrier permeability in patients with cerebral small vessel disease. Sci Rep 2022; 12:7723. [PMID: 35545641 PMCID: PMC9095696 DOI: 10.1038/s41598-022-11172-1] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2022] [Accepted: 04/19/2022] [Indexed: 11/23/2022] Open
Abstract
Cerebral small vessel disease (CSVD) plays an important role in cognitive impairment, stroke, disability, and death. Hypertension is the main risk factor for CSVD. The use of antihypertensive therapy has not resulted in the expected decrease in CSVD complications, which may be related to the underestimation of significance of daily blood pressure profile for blood–brain barrier (BBB) permeability. 53 patients with CSVD of varying severity (mean age 60.08 ± 6.8 years, 69.8% women, subjects with treated long-standing hypertension vs. normotensive subjects − 84.8% vs. 15.2%) and 17 healthy volunteers underwent ambulatory blood pressure monitoring (ABPM) and MRI, including T1-weighted dynamic contrast-enhanced magnetic resonance imaging for assessing BBB permeability. Most of ABPM parameters in CSVD patients did not differ from controls, but were associated with the severity of white matter hyperintensity (WMH) and the total CSVD score. BBB permeability in normal-appearing white matter (NAWM) and grey matter (GM) was significantly higher in CSVD patients, and the severity of BBB permeability remained similar in patients with different stages of WMH. Among BBB permeability parameters, the area under the curve, corresponding to an increase in the contrast transit time in NAWM, had the greatest number of correlations with deviations of ABPM parameters. BBB permeability in CSVD is a universal mechanism of NAWM and GM damage associated with a slight increase in ABPM parameters. It is obvious that the treatment of hypertension in patients with not severe WMH should be more aggressive and carried out under the control of ABPM.
Collapse
|
24
|
van Rijssel AE, Stins BC, Beishon LC, Sanders ML, Quinn TJ, Claassen JA, de Heus RA. Effect of Antihypertensive Treatment on Cerebral Blood Flow in Older Adults: a Systematic Review and Meta-Analysis. Hypertension 2022; 79:1067-1078. [PMID: 35193363 PMCID: PMC8997667 DOI: 10.1161/hypertensionaha.121.18255] [Citation(s) in RCA: 19] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2021] [Accepted: 01/21/2022] [Indexed: 11/16/2022]
Abstract
BACKGROUND In older age, the benefits of antihypertensive treatment (AHT) become less evident, with greater associated risk. Of particular concern is compromising cerebral blood flow (CBF), especially in those with cognitive impairment. METHODS We created a synthesis of the published evidence by searching multiple electronic databases from 1970 to May 2021. Included studies had participants with mean age ≥50 years, hypertension or cognitive impairment, and assessed CBF before and after initiating AHT. Two authors independently determined eligibility and extracted data. Study quality was assessed using The Risk of Bias in Nonrandomized Studies of Interventions tool. We summarized study characteristics (qualitative synthesis) and performed random-effects meta-analyses (quantitative synthesis). RESULTS Thirty-two studies (total n=1306) were included, of which 23 were eligible for meta-analysis. In line with the qualitative synthesis, the meta-analysis indicated no effect of AHT initiation on CBF (standardized mean difference, 0.08 [95% CI, -0.07 to 0.22]; P=0.31, I2=42%). This was consistent across subgroups of acute versus chronic AHT, drug class, study design, and CBF measurement. Subgroups by age demonstrated an increase in CBF after AHT in those aged >70 years (standardized mean difference, 4.15 [95% CI, 0.16-8.15]; P=0.04, I2=42%), but not in those aged 50 to 65 and 65 to 70 years (standardized mean difference, 0.18 [95% CI,-2.02 to 2.38]; P=0.87, I2=49%; standardized mean difference, 1.22 [95% CI, -0.45 to 2.88]; P=0.15, I2=68%). Overall, risk of bias was moderate-to-high and quality of evidence (Grading of Recommendations Assessment, Development and Evaluation) was very low, reflecting the observational nature of the data. CONCLUSIONS Accepting the observed limitations, current evidence does not suggest a harmful effect of AHT on CBF. Concerns over CBF should not preclude treatment of hypertension.
Collapse
Affiliation(s)
- Anniek E. van Rijssel
- Radboud university medical center, Donders Institute for Brain Cognition and Behaviour, Department of Geriatric Medicine, Radboudumc Alzheimer Center, Nijmegen, the Netherlands (A.E.v.R., B.C.S., M.L.S., J.A.H.R.C., R.A.A.d.H.)
| | - Bram C. Stins
- Radboud university medical center, Donders Institute for Brain Cognition and Behaviour, Department of Geriatric Medicine, Radboudumc Alzheimer Center, Nijmegen, the Netherlands (A.E.v.R., B.C.S., M.L.S., J.A.H.R.C., R.A.A.d.H.)
| | - Lucy C. Beishon
- Department of Cardiovascular Sciences, University of Leicester, United Kingdom (L.C.B.)
| | - Marit L. Sanders
- Radboud university medical center, Donders Institute for Brain Cognition and Behaviour, Department of Geriatric Medicine, Radboudumc Alzheimer Center, Nijmegen, the Netherlands (A.E.v.R., B.C.S., M.L.S., J.A.H.R.C., R.A.A.d.H.)
| | - Terence J. Quinn
- Institute of Cardiovascular and Medical Sciences, University of Glasgow, United Kingdom (T.J.Q.)
| | - Jurgen A.H.R. Claassen
- Radboud university medical center, Donders Institute for Brain Cognition and Behaviour, Department of Geriatric Medicine, Radboudumc Alzheimer Center, Nijmegen, the Netherlands (A.E.v.R., B.C.S., M.L.S., J.A.H.R.C., R.A.A.d.H.)
| | - Rianne A.A. de Heus
- Radboud university medical center, Donders Institute for Brain Cognition and Behaviour, Department of Geriatric Medicine, Radboudumc Alzheimer Center, Nijmegen, the Netherlands (A.E.v.R., B.C.S., M.L.S., J.A.H.R.C., R.A.A.d.H.)
| |
Collapse
|
25
|
Cerebral small vessel disease alters neurovascular unit regulation of microcirculation integrity involved in vascular cognitive impairment. Neurobiol Dis 2022; 170:105750. [DOI: 10.1016/j.nbd.2022.105750] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2021] [Revised: 03/09/2022] [Accepted: 05/08/2022] [Indexed: 12/25/2022] Open
|
26
|
Qu P, Cheng K, Gao Q, Li Y, Wang M. Application Value of Serum Hcy, TLR4, and CRP in the Diagnosis of Cerebral Small Vessel Disease. EVIDENCE-BASED COMPLEMENTARY AND ALTERNATIVE MEDICINE : ECAM 2022; 2022:4025965. [PMID: 35502170 PMCID: PMC9056226 DOI: 10.1155/2022/4025965] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/11/2022] [Revised: 03/22/2022] [Accepted: 04/09/2022] [Indexed: 11/18/2022]
Abstract
Objective To evaluate the application value of combined detection of serum homocysteine (Hcy), Toll-like receptor 4 (TLR4), and C-reactive protein (CRP) in the diagnosis of cerebral small vessel disease (CSVD). Methods 90 patients with CSVD admitted to our hospital within the past year were identified as the research subjects, and the patients with cognitive dysfunction were assigned to the experimental group, and those with normal cognitive function were assigned to the control group according to the evaluation of cognitive dysfunction by the Montreal Cognitive Assessment (MoCA), with 45 cases in each group. Results The experimental group obtained remarkably elevated Hcy levels than the control group (P < 0.05). The patient's cognitive dysfunction is mainly attributed to the impact of serum Hcy. TLR4 and Hcy were negatively correlated with MoCA scores (P > 0.05). In comparison with the control group, the experimental group had significantly higher levels of Hcy, serum CRP, and interleukin (IL)-6 (P < 0.05). Conclusion The combined detection of serum Hcy, TLR4, and CRP features a high clinical value in the diagnosis of CSVD, which contributes to the prevention and treatment of cognitive dysfunction in patients.
Collapse
Affiliation(s)
- Peng Qu
- Department of Neurology, The Fifth Affiliated Hospital of Harbin Medical University, Harbin, China
| | - Kaili Cheng
- Department of Neurology, The Fifth Affiliated Hospital of Harbin Medical University, Harbin, China
| | - Qi Gao
- Department of Neurology, The Fifth Affiliated Hospital of Harbin Medical University, Harbin, China
| | - Yan Li
- Department of Neurology, The Fifth Affiliated Hospital of Harbin Medical University, Harbin, China
| | - Minghua Wang
- Department of Neurology, The Fifth Affiliated Hospital of Harbin Medical University, Harbin, China
| |
Collapse
|
27
|
Webb AJ, Lawson A, Wartolowska K, Mazzucco S, Rothwell PM. Aortic Stiffness, Pulse Pressure, and Cerebral Pulsatility Progress Despite Best Medical Management: The OXVASC Cohort. Stroke 2022; 53:1310-1317. [PMID: 34852644 PMCID: PMC7612543 DOI: 10.1161/strokeaha.121.035560] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2021] [Revised: 08/26/2021] [Accepted: 10/06/2021] [Indexed: 12/23/2022]
Abstract
BACKGROUND Increased cerebral arterial pulsatility is associated with cerebral small vessel disease, recurrent stroke, and dementia despite the best medical treatment. However, no study has identified the rates and determinants of progression of arterial stiffness and pulsatility. METHODS In consecutive patients within 6 weeks of transient ischemic attack or nondisabling stroke (OXVASC [Oxford Vascular Study]), arterial stiffness (pulse wave velocity [PWV]) and aortic systolic, aortic diastolic, and aortic pulse pressures (aoPP) were measured by applanation tonometry (Sphygmocor), while middle cerebral artery (MCA) peak (MCA-PSV) and trough (MCA-EDV) flow velocity and Gosling pulsatility index (PI; MCA-PI) were measured by transcranial ultrasound (transcranial Doppler, DWL Doppler Box). Repeat assessments were performed at the 5-year follow-up visit after intensive medical treatment and agreement determined by intraclass correlation coefficients. Rates of progression and their determinants, stratified by age and sex, were determined by mixed-effects linear models, adjusted for age, sex, and cardiovascular risk factors. RESULTS In 188 surviving, eligible patients with repeat assessments after a median of 5.8 years. PWV, aoPP, and MCA-PI were highly reproducible (intraclass correlation coefficients, 0.71, 0.59, and 0.65, respectively), with progression of PWV (2.4%; P<0.0001) and aoPP (3.5%; P<0.0001) but not significantly for MCA-PI overall (0.93; P=0.22). However, PWV increased at a faster rate with increasing age (0.009 m/s per y/y; P<0.0001), while aoPP and MCA-PI increased significantly above the age of 55 years (aoPP, P<0.0001; MCA-PI, P=0.009). Higher aortic systolic blood pressure and diastolic blood pressure predicted a greater rate of progression of PWV and aoPP, but not MCA-PI, although current MCA-PI was particularly strongly associated with concurrent aoPP (P<0.001). CONCLUSIONS Arterial pulsatility and aortic stiffness progressed significantly after 55 years of age despite the best medical treatment. Progression of stiffness and aoPP was determined by high blood pressure, but MCA-PI predominantly reflected current aoPP. Treatments targetting cerebral pulsatility may need to principally target aortic stiffness and pulse pressure to have the potential to prevent cerebral small vessel disease.
Collapse
Affiliation(s)
- Alastair J.S. Webb
- Department of Clinical Neurosciences, Wolfson Centre for Prevention of Stroke and Dementia, University of Oxford, United Kingdom
| | - Amy Lawson
- Department of Clinical Neurosciences, Wolfson Centre for Prevention of Stroke and Dementia, University of Oxford, United Kingdom
| | - Karolina Wartolowska
- Department of Clinical Neurosciences, Wolfson Centre for Prevention of Stroke and Dementia, University of Oxford, United Kingdom
| | - Sara Mazzucco
- Department of Clinical Neurosciences, Wolfson Centre for Prevention of Stroke and Dementia, University of Oxford, United Kingdom
| | - Peter M. Rothwell
- Department of Clinical Neurosciences, Wolfson Centre for Prevention of Stroke and Dementia, University of Oxford, United Kingdom
| |
Collapse
|
28
|
Abstract
Despite advances in acute management and prevention of cerebrovascular disease, stroke and vascular cognitive impairment together remain the world's leading cause of death and neurological disability. Hypertension and its consequences are associated with over 50% of ischemic and 70% of hemorrhagic strokes but despite good control of blood pressure (BP), there remains a 10% risk of recurrent cerebrovascular events, and there is no proven strategy to prevent vascular cognitive impairment. Hypertension evolves over the lifespan, from predominant sympathetically driven hypertension with elevated mean BP in early and mid-life to a late-life phenotype of increasing systolic and falling diastolic pressures, associated with increased arterial stiffness and aortic pulsatility. This pattern may partially explain both the increasing incidence of stroke in younger adults as well as late-onset, chronic cerebrovascular injury associated with concurrent systolic hypertension and historic mid-life diastolic hypertension. With increasing arterial stiffness and autonomic dysfunction, BP variability increases, independently predicting the risk of ischemic and intracerebral hemorrhage, and is potentially modifiable beyond control of mean BP. However, the interaction between hypertension and control of cerebral blood flow remains poorly understood. Cerebral small vessel disease is associated with increased pulsatility in large cerebral vessels and reduced reactivity to carbon dioxide, both of which are being targeted in early phase clinical trials. Cerebral arterial pulsatility is mainly dependent upon increased transmission of aortic pulsatility via stiff vessels to the brain, while cerebrovascular reactivity reflects endothelial dysfunction. In contrast, although cerebral autoregulation is critical to adapt cerebral tone to BP fluctuations to maintain cerebral blood flow, its role as a modifiable risk factor for cerebrovascular disease is uncertain. New insights into hypertension-associated cerebrovascular pathophysiology may provide key targets to prevent chronic cerebrovascular disease, acute events, and vascular cognitive impairment.
Collapse
Affiliation(s)
- Alastair J S Webb
- Wolfson Centre for Prevention of Stroke and Dementia, University of Oxford, United Kingdom (A.J.S.W.)
| | - David J Werring
- Stroke Research Centre, UCL Queen Square Institute of Neurology, London, United Kingdom (D.J.W.)
| |
Collapse
|
29
|
Dolui S, Detre JA, Gaussoin SA, Herrick JS, Wang DJJ, Tamura MK, Cho ME, Haley WE, Launer LJ, Punzi HA, Rastogi A, Still CH, Weiner DE, Wright JT, Williamson JD, Wright CB, Bryan RN, Bress AP, Pajewski NM, Nasrallah IM. Association of Intensive vs Standard Blood Pressure Control With Cerebral Blood Flow: Secondary Analysis of the SPRINT MIND Randomized Clinical Trial. JAMA Neurol 2022; 79:380-389. [PMID: 35254390 PMCID: PMC8902686 DOI: 10.1001/jamaneurol.2022.0074] [Citation(s) in RCA: 24] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
IMPORTANCE Antihypertensive treatments benefit cerebrovascular health and cognitive function in patients with hypertension, but it is uncertain whether an intensive blood pressure target leads to potentially harmful cerebral hypoperfusion. OBJECTIVE To investigate the association of intensive systolic blood pressure (SBP) control vs standard control with whole-brain cerebral blood flow (CBF). DESIGN, SETTING, AND PARTICIPANTS This substudy of the Systolic Blood Pressure Intervention Trial (SPRINT) randomized clinical trial compared the efficacy of 2 different blood pressure-lowering strategies with longitudinal brain magnetic resonance imaging (MRI) including arterial spin labeled perfusion imaging to quantify CBF. A total of 1267 adults 50 years or older with hypertension and increased cardiovascular risk but free of diabetes or dementia were screened for the SPRINT substudy from 6 sites in the US. Randomization began in November 2010 with final follow-up MRI in July 2016. Analyses were performed from September 2020 through December 2021. INTERVENTIONS Study participants with baseline CBF measures were randomized to an intensive SBP target less than 120 mm Hg or standard SBP target less than 140 mm Hg. MAIN OUTCOMES AND MEASURES The primary outcome was change in whole-brain CBF from baseline. Secondary outcomes were change in gray matter, white matter, and periventricular white matter CBF. RESULTS Among 547 participants with CBF measured at baseline, the mean (SD) age was 67.5 (8.1) years and 219 (40.0%) were women; 315 completed follow-up MRI at a median (IQR) of 4.0 (3.7-4.1) years after randomization. Mean whole-brain CBF increased from 38.90 to 40.36 (difference, 1.46 [95% CI, 0.08-2.83]) mL/100 g/min in the intensive treatment group, with no mean increase in the standard treatment group (37.96 to 37.12; difference, -0.84 [95% CI, -2.30 to 0.61] mL/100 g/min; between-group difference, 2.30 [95% CI, 0.30-4.30; P = .02]). Gray, white, and periventricular white matter CBF showed similar changes. The association of intensive vs standard treatment with CBF was generally similar across subgroups defined by age, sex, race, chronic kidney disease, SBP, orthostatic hypotension, and frailty, with the exception of an indication of larger mean increases in CBF associated with intensive treatment among participants with a history of cardiovascular disease (interaction P = .05). CONCLUSIONS AND RELEVANCE Intensive vs standard antihypertensive treatment was associated with increased, rather than decreased, cerebral perfusion, most notably in participants with a history of cardiovascular disease. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT01206062.
Collapse
Affiliation(s)
- Sudipto Dolui
- Department of Radiology, University of Pennsylvania, Philadelphia
| | - John A Detre
- Department of Radiology, University of Pennsylvania, Philadelphia.,Department of Neurology, University of Pennsylvania, Philadelphia
| | - Sarah A Gaussoin
- Department of Biostatistics and Data Science, Wake Forest School of Medicine, Winston-Salem, North Carolina
| | - Jennifer S Herrick
- Department of Population Health Sciences, University of Utah, Salt Lake City
| | - Danny J J Wang
- Laboratory of FMRI Technology, Mark & Mary Stevens Neuroimaging and Informatics Institute, Keck School of Medicine, University of Southern California, Los Angeles.,Department of Neurology, Keck School of Medicine, University of Southern California, Los Angeles
| | - Manjula Kurella Tamura
- Geriatric Research and Education Clinical Center, Palo Alto Veterans Affairs Health Care System, Palo Alto, California.,Division of Nephrology, Stanford University School of Medicine, Palo Alto, California
| | - Monique E Cho
- Division of Nephrology and Hypertension, University of Utah, Salt Lake City
| | - William E Haley
- Department of Nephrology and Hypertension, Mayo Clinic, Jacksonville, Florida
| | - Lenore J Launer
- Intramural Research Program, National Institute on Aging, Baltimore, Maryland
| | - Henry A Punzi
- Trinity Hypertension and Metabolic Research Institute, Punzi Medical Center, Carrollton, Texas.,Department of Family and Community Medicine, University of Texas Southwestern Medical Center, Dallas
| | - Anjay Rastogi
- Department of Medicine, University of California at Los Angeles School of Medicine, Los Angeles
| | - Carolyn H Still
- Frances Payne Bolton School of Nursing, Case Western Reserve University, Cleveland, Ohio
| | - Daniel E Weiner
- William B. Schwartz, MD, Division of Nephrology, Tufts Medical Center, Boston, Massachusetts
| | - Jackson T Wright
- Division of Nephrology and Hypertension, University Hospitals Cleveland Medical Center, Case Western Reserve University, Cleveland, Ohio
| | - Jeff D Williamson
- Sticht Center on Healthy Aging and Alzheimer's Prevention, Department of Internal Medicine, Wake Forest School of Medicine, Winston-Salem, North Carolina
| | - Clinton B Wright
- Stroke Branch (intramural)/Division of Clinical Research (extramural), National Institute of Neurological Disorders and Stroke, Bethesda, Maryland
| | - R Nick Bryan
- Department of Diagnostic Medicine; Dell Medical School, University of Texas at Austin, Austin
| | - Adam P Bress
- Department of Population Health Sciences, University of Utah, Salt Lake City
| | - Nicholas M Pajewski
- Department of Biostatistics and Data Science, Wake Forest School of Medicine, Winston-Salem, North Carolina
| | - Ilya M Nasrallah
- Department of Radiology, University of Pennsylvania, Philadelphia
| |
Collapse
|
30
|
Dobrynina L, Shamtieva K, Kremneva E, Zabitova M, Gadzhieva Z, Krotenkova M. Controlled arterial hypertension and blood-brain barrier damage in patients with age-related cerebral small vessel disease and cognitive impairments. Zh Nevrol Psikhiatr Im S S Korsakova 2022; 122:74-79. [DOI: 10.17116/jnevro202212211174] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
|
31
|
Liu Z, Ma H, Guo ZN, Wang L, Qu Y, Fan L, Liu X, Liu J, Zhu Y, Yang Y. Impaired dynamic cerebral autoregulation is associated with the severity of neuroimaging features of cerebral small vessel disease. CNS Neurosci Ther 2021; 28:298-306. [PMID: 34894087 PMCID: PMC8739047 DOI: 10.1111/cns.13778] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2021] [Revised: 11/22/2021] [Accepted: 11/23/2021] [Indexed: 12/21/2022] Open
Abstract
Aims Cerebral small vessel disease (CSVD) is characterized by functional and structural changes in small vessels. We aimed to elucidate the relationship between dynamic cerebral autoregulation (dCA) and neuroimaging characteristics of CSVD. Methods A case‐control study was performed. Cerebral blood flow velocity (CBFV) of bilateral middle cerebral arteries and spontaneous arterial blood pressure were simultaneously recorded. Transfer function analysis was used to calculate dCA parameters (phase, gain, and the rate of recovery of CBFV [RoRc]). Neuroimaging characteristics of CSVD patients were evaluated, including lacunes, white matter hyperintensities (WMH), cerebral microbleeds (CMBs), perivascular spaces (PVS), and the total CSVD burden. Results Overall, 113 patients and 83 controls were enrolled. Compared with the control group, the phase at low frequency and the RoRc in CSVD patients were lower, and the gain at very low and low frequencies were higher, indicating bilaterally impaired dCA. Total CSVD burden, WMH (total, periventricular and deep), severe PVS, and lobar CMBs were independently correlated with the phase at low frequency. Conclusions Our findings suggested that dCA was compromised in CSVD patients, and some specific neuroimaging characteristics (the total CSVD burden, WMH, severe PVS and lobar CMBs) might indicate more severe dCA impairment in CSVD patients.
Collapse
Affiliation(s)
- Zhaojun Liu
- Stroke Center & Clinical Trial and Research Center for Stroke, Department of Neurology, The First Hospital of Jilin University, Changchun, China.,China National Comprehensive Stroke Center, Changchun, China.,Jilin Provincial Key Laboratory of Cerebrovascular Disease, Changchun, China
| | - Hongyin Ma
- Stroke Center & Clinical Trial and Research Center for Stroke, Department of Neurology, The First Hospital of Jilin University, Changchun, China.,China National Comprehensive Stroke Center, Changchun, China.,Jilin Provincial Key Laboratory of Cerebrovascular Disease, Changchun, China
| | - Zhen-Ni Guo
- Stroke Center & Clinical Trial and Research Center for Stroke, Department of Neurology, The First Hospital of Jilin University, Changchun, China.,China National Comprehensive Stroke Center, Changchun, China.,Jilin Provincial Key Laboratory of Cerebrovascular Disease, Changchun, China
| | - Le Wang
- Stroke Center & Clinical Trial and Research Center for Stroke, Department of Neurology, The First Hospital of Jilin University, Changchun, China.,China National Comprehensive Stroke Center, Changchun, China.,Jilin Provincial Key Laboratory of Cerebrovascular Disease, Changchun, China
| | - Yang Qu
- Stroke Center & Clinical Trial and Research Center for Stroke, Department of Neurology, The First Hospital of Jilin University, Changchun, China.,China National Comprehensive Stroke Center, Changchun, China.,Jilin Provincial Key Laboratory of Cerebrovascular Disease, Changchun, China
| | - Lei Fan
- Department of Neurology, The First Hospital of Hebei North University, Zhangjiakou, China
| | - Xingliang Liu
- Department of Neurology, The First Hospital of Hebei North University, Zhangjiakou, China
| | - Jie Liu
- Department of Neurology, The People's Hospital of Lixin County, Haozhou, China
| | - Yuanyuan Zhu
- Department of Neurology, The People's Hospital of Lixin County, Haozhou, China
| | - Yi Yang
- Stroke Center & Clinical Trial and Research Center for Stroke, Department of Neurology, The First Hospital of Jilin University, Changchun, China.,China National Comprehensive Stroke Center, Changchun, China.,Jilin Provincial Key Laboratory of Cerebrovascular Disease, Changchun, China
| |
Collapse
|
32
|
Blair GW, Janssen E, Stringer MS, Thrippleton MJ, Chappell F, Shi Y, Hamilton I, Flaherty K, Appleton JP, Doubal FN, Bath PM, Wardlaw JM. Effects of Cilostazol and Isosorbide Mononitrate on Cerebral Hemodynamics in the LACI-1 Randomized Controlled Trial. Stroke 2021; 53:29-33. [PMID: 34847709 PMCID: PMC8700302 DOI: 10.1161/strokeaha.121.034866] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
Supplemental Digital Content is available in the text. Cerebral small vessel disease—a major cause of stroke and dementia—is associated with cerebrovascular dysfunction. We investigated whether short-term isosorbide mononitrate (ISMN) and cilostazol, alone or in combination, improved magnetic resonance imaging–measured cerebrovascular function in patients with lacunar ischemic stroke.
Collapse
Affiliation(s)
- Gordon W Blair
- Brain Research Imaging Centre, Centre for Clinical Brain Sciences, UK Dementia Institute Centre at the University of Edinburgh, United Kingdom (G.W.B., M.S.S., M.J.T., F.C., Y.S., I.H., F.N.D., J.M.W.)
| | - Esther Janssen
- Department of Neurology, Donders Institute for Brain, Cognition and Behaviour, Donders Centre for Medical Neuroscience, Radboud University Medical Center, Nijmegen, the Netherlands (E.J.)
| | - Michael S Stringer
- Brain Research Imaging Centre, Centre for Clinical Brain Sciences, UK Dementia Institute Centre at the University of Edinburgh, United Kingdom (G.W.B., M.S.S., M.J.T., F.C., Y.S., I.H., F.N.D., J.M.W.)
| | - Michael J Thrippleton
- Brain Research Imaging Centre, Centre for Clinical Brain Sciences, UK Dementia Institute Centre at the University of Edinburgh, United Kingdom (G.W.B., M.S.S., M.J.T., F.C., Y.S., I.H., F.N.D., J.M.W.)
| | - Francesca Chappell
- Brain Research Imaging Centre, Centre for Clinical Brain Sciences, UK Dementia Institute Centre at the University of Edinburgh, United Kingdom (G.W.B., M.S.S., M.J.T., F.C., Y.S., I.H., F.N.D., J.M.W.)
| | - Yulu Shi
- Brain Research Imaging Centre, Centre for Clinical Brain Sciences, UK Dementia Institute Centre at the University of Edinburgh, United Kingdom (G.W.B., M.S.S., M.J.T., F.C., Y.S., I.H., F.N.D., J.M.W.)
| | - Iona Hamilton
- Brain Research Imaging Centre, Centre for Clinical Brain Sciences, UK Dementia Institute Centre at the University of Edinburgh, United Kingdom (G.W.B., M.S.S., M.J.T., F.C., Y.S., I.H., F.N.D., J.M.W.)
| | - Katie Flaherty
- Stroke Trials Unit, Division of Clinical Neuroscience, University of Nottingham, United Kingdom (K.F., J.P.A., P.M.B.)
| | - Jason P Appleton
- Stroke Trials Unit, Division of Clinical Neuroscience, University of Nottingham, United Kingdom (K.F., J.P.A., P.M.B.).,Stroke, University Hospitals Birmingham NHS Foundation Trust, Queen Elizabeth Hospital, Mindelsohn Way, United Kingdom (J.P.A.)
| | - Fergus N Doubal
- Brain Research Imaging Centre, Centre for Clinical Brain Sciences, UK Dementia Institute Centre at the University of Edinburgh, United Kingdom (G.W.B., M.S.S., M.J.T., F.C., Y.S., I.H., F.N.D., J.M.W.)
| | - Philip M Bath
- Stroke Trials Unit, Division of Clinical Neuroscience, University of Nottingham, United Kingdom (K.F., J.P.A., P.M.B.).,Stroke, Queen's Medical Centre Campus, Nottingham University Hospitals NHS Trust, United Kingdom (P.M.B.)
| | - Joanna M Wardlaw
- Brain Research Imaging Centre, Centre for Clinical Brain Sciences, UK Dementia Institute Centre at the University of Edinburgh, United Kingdom (G.W.B., M.S.S., M.J.T., F.C., Y.S., I.H., F.N.D., J.M.W.)
| |
Collapse
|
33
|
Elhassanien MEM, El-Heneedy YAE, Ramadan KM, Kotait MA, Elkholy A, Elhamrawy MY, Bahnasy WS. Gait and balance impairments in patients with subcortical vascular cognitive impairment. THE EGYPTIAN JOURNAL OF NEUROLOGY, PSYCHIATRY AND NEUROSURGERY 2021. [DOI: 10.1186/s41983-021-00293-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
Abstract
Background
Subcortical vascular cognitive impairment (SVCI) is a subtype of vascular cognitive impairment associated with extensive cerebral small vessel diseases (CSVDs) imaging biomarkers. The objectives of this work were to study the existence and patterns of gait and balance impairments in patients with SVCI due to CSVDs.
Methods
The study was conducted on 28 newly diagnosed SVCI patients and 22 healthy control subjects (HCS) submitted to the advanced activity of daily living scale (AADLs), Berg balance test (BBT), Montreal Cognitive Assessment Scale (MoCA), computerized dynamic posturography (CDP), vision-based 3-D skeletal data gait analysis, and brain MRI volumetric assessment.
Results
SVCI patients showed a significant decrease in AADLs as well as total cerebral white matter volume, total cerebral cortical volume, and mean cortical thickness which were proportional to the degree of cognitive impairment as measured by the MoCA score. Regarding CDP analysis, patients with SVCI revealed prolongation of cancelation time and spectral power for mid- and high frequencies in dynamic positions. In respect to gait analysis, there were significant decreases in mean stride length and mean cadence as well as increases in mean step width and left to right step length difference in the SVCI group compared to HCS while doing a single task. These variables get highly significant during the dual-task performance with a p value < 0.001 for each one.
Conclusion
Patients with SVCI suffer from gait and balance impairments that are proportional to the severity of their cognitive decline and greatly impair their ADLs.
Collapse
|
34
|
Jiménez-Sánchez L, Hamilton OKL, Clancy U, Backhouse EV, Stewart CR, Stringer MS, Doubal FN, Wardlaw JM. Sex Differences in Cerebral Small Vessel Disease: A Systematic Review and Meta-Analysis. Front Neurol 2021; 12:756887. [PMID: 34777227 PMCID: PMC8581736 DOI: 10.3389/fneur.2021.756887] [Citation(s) in RCA: 22] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2021] [Accepted: 10/04/2021] [Indexed: 01/12/2023] Open
Abstract
Background: Cerebral small vessel disease (SVD) is a common cause of stroke, mild cognitive impairment, dementia and physical impairments. Differences in SVD incidence or severity between males and females are unknown. We assessed sex differences in SVD by assessing the male-to-female ratio (M:F) of recruited participants and incidence of SVD, risk factor presence, distribution, and severity of SVD features. Methods: We assessed four recent systematic reviews on SVD and performed a supplementary search of MEDLINE to identify studies reporting M:F ratio in covert, stroke, or cognitive SVD presentations (registered protocol: CRD42020193995). We meta-analyzed differences in sex ratios across time, countries, SVD severity and presentations, age and risk factors for SVD. Results: Amongst 123 relevant studies (n = 36,910 participants) including 53 community-based, 67 hospital-based and three mixed studies published between 1989 and 2020, more males were recruited in hospital-based than in community-based studies [M:F = 1.16 (0.70) vs. M:F = 0.79 (0.35), respectively; p < 0.001]. More males had moderate to severe SVD [M:F = 1.08 (0.81) vs. M:F = 0.82 (0.47) in healthy to mild SVD; p < 0.001], and stroke presentations where M:F was 1.67 (0.53). M:F did not differ for recent (2015-2020) vs. pre-2015 publications, by geographical region, or age. There were insufficient sex-stratified data to explore M:F and risk factors for SVD. Conclusions: Our results highlight differences in male-to-female ratios in SVD severity and amongst those presenting with stroke that have important clinical and translational implications. Future SVD research should report participant demographics, risk factors and outcomes separately for males and females. Systematic Review Registration: [PROSPERO], identifier [CRD42020193995].
Collapse
Affiliation(s)
- Lorena Jiménez-Sánchez
- Translational Neuroscience PhD Programme, Centre for Clinical Brain Sciences, University of Edinburgh, Edinburgh, United Kingdom
| | - Olivia K. L. Hamilton
- Translational Neuroscience PhD Programme, Centre for Clinical Brain Sciences, University of Edinburgh, Edinburgh, United Kingdom
- Edinburgh Dementia Research Centre in the UK Dementia Research Institute, Edinburgh, United Kingdom
| | - Una Clancy
- Edinburgh Dementia Research Centre in the UK Dementia Research Institute, Edinburgh, United Kingdom
- Centre for Clinical Brain Sciences, University of Edinburgh, Edinburgh, United Kingdom
| | - Ellen V. Backhouse
- Edinburgh Dementia Research Centre in the UK Dementia Research Institute, Edinburgh, United Kingdom
- Centre for Clinical Brain Sciences, University of Edinburgh, Edinburgh, United Kingdom
| | - Catriona R. Stewart
- Edinburgh Dementia Research Centre in the UK Dementia Research Institute, Edinburgh, United Kingdom
- Centre for Clinical Brain Sciences, University of Edinburgh, Edinburgh, United Kingdom
| | - Michael S. Stringer
- Edinburgh Dementia Research Centre in the UK Dementia Research Institute, Edinburgh, United Kingdom
- Centre for Clinical Brain Sciences, University of Edinburgh, Edinburgh, United Kingdom
| | - Fergus N. Doubal
- Edinburgh Dementia Research Centre in the UK Dementia Research Institute, Edinburgh, United Kingdom
- Centre for Clinical Brain Sciences, University of Edinburgh, Edinburgh, United Kingdom
| | - Joanna M. Wardlaw
- Edinburgh Dementia Research Centre in the UK Dementia Research Institute, Edinburgh, United Kingdom
- Centre for Clinical Brain Sciences, University of Edinburgh, Edinburgh, United Kingdom
- Lothian Birth Cohorts, University of Edinburgh, Edinburgh, United Kingdom
| |
Collapse
|
35
|
Wang X, Minhas JS, Moullaali TJ, Luca Di Tanna G, Lindley RI, Chen X, Arima H, Chen G, Delcourt C, Bath PM, Broderick JP, Demchuk AM, Donnan GA, Durham AC, Lavados PM, Lee TH, Levi C, Martins SO, Olavarria VV, Pandian JD, Parsons MW, Pontes-Neto OM, Ricci S, Sato S, Sharma VK, Silva F, Thang NH, Wang JG, Woodward M, Chalmers J, Song L, Anderson CS, Robinson TG. Associations of Early Systolic Blood Pressure Control and Outcome After Thrombolysis-Eligible Acute Ischemic Stroke: Results From the ENCHANTED Study. Stroke 2021; 53:779-787. [PMID: 34702064 DOI: 10.1161/strokeaha.121.034580] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
BACKGROUND AND PURPOSE In thrombolysis-eligible patients with acute ischemic stroke, there is uncertainty over the most appropriate systolic blood pressure (SBP) lowering profile that provides an optimal balance of potential benefit (functional recovery) and harm (intracranial hemorrhage). We aimed to determine relationships of SBP parameters and outcomes in thrombolyzed acute ischemic stroke patients. METHODS Post hoc analyzes of the ENCHANTED (Enhanced Control of Hypertension and Thrombolysis Stroke Study), a partial-factorial trial of thrombolysis-eligible and treated acute ischemic stroke patients with high SBP (150-180 mm Hg) assigned to low-dose (0.6 mg/kg) or standard-dose (0.9 mg/kg) alteplase and intensive (target SBP, 130-140 mm Hg) or guideline-recommended (target SBP <180 mm Hg) treatment. All patients were followed up for functional status and serious adverse events to 90 days. Logistic regression models were used to analyze 3 SBP summary measures postrandomization: attained (mean), variability (SD) in 1-24 hours, and magnitude of reduction in 1 hour. The primary outcome was a favorable shift on the modified Rankin Scale. The key safety outcome was any intracranial hemorrhage. RESULTS Among 4511 included participants (mean age 67 years, 38% female, 65% Asian) lower attained SBP and smaller SBP variability were associated with favorable shift on the modified Rankin Scale (per 10 mm Hg increase: odds ratio, 0.76 [95% CI, 0.71-0.82], P<0.001 and 0.86 [95% CI, 0.76-0.98], P=0.025) respectively, but not for magnitude of SBP reduction (0.98, [0.93-1.04], P=0.564). Odds of intracranial hemorrhage was associated with higher attained SBP and greater SBP variability (1.18 [1.06-1.31], P=0.002 and 1.34 [1.11-1.62], P=0.002) but not with magnitude of SBP reduction (1.05 [0.98-1.14], P=0.184). CONCLUSIONS Attaining early and consistent low levels in SBP <140 mm Hg, even as low as 110 to 120 mm Hg, over 24 hours is associated with better outcomes in thrombolyzed acute ischemic stroke patients. REGISTRATION URL: https://www.clinicaltrials.gov; Unique identifier: NCT01422616.
Collapse
Affiliation(s)
- Xia Wang
- The George Institute for Global Health, University of New South Wales, Australia (X.W., T.J.M., G.L.D.T., X.C., H.A., C.D., M.W., J.C., L.S., C.S.A)
| | - Jatinder S Minhas
- Department of Cardiovascular Sciences, University of Leicester, United Kingdom. (J.S.M., T.G.R.).,National Institute for Health Research Leicester Biomedical Research Centre, United Kingdom (J.S.M., T.G.R.)
| | - Tom J Moullaali
- The George Institute for Global Health, University of New South Wales, Australia (X.W., T.J.M., G.L.D.T., X.C., H.A., C.D., M.W., J.C., L.S., C.S.A).,Centre for Clinical Brain Sciences, University of Edinburgh, United Kingdom (T.J.M.)
| | - Gian Luca Di Tanna
- The George Institute for Global Health, University of New South Wales, Australia (X.W., T.J.M., G.L.D.T., X.C., H.A., C.D., M.W., J.C., L.S., C.S.A)
| | - Richard I Lindley
- Westmead Applied Research Centre, University of Sydney, NSW, Australia. (R.I.L.)
| | - Xiaoying Chen
- The George Institute for Global Health, University of New South Wales, Australia (X.W., T.J.M., G.L.D.T., X.C., H.A., C.D., M.W., J.C., L.S., C.S.A)
| | - Hisatomi Arima
- The George Institute for Global Health, University of New South Wales, Australia (X.W., T.J.M., G.L.D.T., X.C., H.A., C.D., M.W., J.C., L.S., C.S.A).,Department of Preventive Medicine and Public Health, Faculty of Medicine, Fukuoka University, Japan (H.A.)
| | - Guofang Chen
- Department of Neurology, Xuzhou Central Hospital, China (G.C.)
| | - Candice Delcourt
- The George Institute for Global Health, University of New South Wales, Australia (X.W., T.J.M., G.L.D.T., X.C., H.A., C.D., M.W., J.C., L.S., C.S.A).,Department of Clinical Medicine, Faculty of Medicine, Health and Human Sciences, Macquarie University, Macquarie Park, New South Wales, Australia (C.D.)
| | - Philip M Bath
- Stroke Trials Unit, School of Medicine, University of Nottingham, United Kingdom (P.M.B.)
| | - Joseph P Broderick
- Department of Neurology and Rehabilitation Medicine, University of Cincinnati Neuroscience Institute, University of Cincinnati, OH (J.P.B.).,Department of Neurology and Psychiatry, Clinica Alemana de Santiago, Clinica Alemana Universidad del Desarrollo School of Medicine, Santiago, Chile (P.M.L., V.V.O.)
| | - Andrew M Demchuk
- Department of Clinical Neurosciences and Radiology, Hotchkiss Brain Institute, Cumming School of Medicine, University of Calgary, Canada (A.M.D.)
| | - Geoffrey A Donnan
- Department of Melbourne Brain Centre, Royal Melbourne Hospital, University of Melbourne, Victoria, Australia. (G.A.D.)
| | - Alice C Durham
- Department of Cardiovascular Sciences, University of Leicester, United Kingdom. (A.C.D.)
| | - Pablo M Lavados
- Department of Neurology and Psychiatry, Clinica Alemana de Santiago, Clinica Alemana Universidad del Desarrollo School of Medicine, Santiago, Chile (P.M.L., V.V.O.)
| | - Tsong-Hai Lee
- Stroke Center and Department of Neurology, Linkou Chang Gung Memorial Hospital and College of Medicine, Chang Gung University, Taoyuan, Taiwan (T.-H.L.)
| | - Christopher Levi
- University of Newcastle, School of Medicine and Public Health, University Drive, Callaghan, NSW, Australia (C.L.).,Hunter Medical Research Institute, New Lambton Heights, Australia (C.L.).,The Sydney Partnership for Health, Education, Research and Enterprise, Ingham Institute for Applied Medical Research, Liverpool, NSW, Australia (C.L.)
| | - Sheila O Martins
- Stroke Division of Neurology Service, Hospital de Clinicas de Porto Alegre, University of Rio Grande do Sul, Porto Alegre, Brazil (S.O.M.)
| | - Veronica V Olavarria
- Department of Neurology and Psychiatry, Clinica Alemana de Santiago, Clinica Alemana Universidad del Desarrollo School of Medicine, Santiago, Chile (P.M.L., V.V.O.)
| | - Jeyaraj D Pandian
- Department of Neurology, Christian Medical College, Ludhiana, Punjab, India (J.D.P.)
| | - Mark W Parsons
- The George Institute for Global Health, University of New South Wales, Australia (X.W., T.J.M., G.L.D.T., X.C., H.A., C.D., M.W., J.C., L.S., C.S.A).,Department of Neurology Department, Royal Melbourne Hospital, University of Melbourne, Victoria, Australia. (M.W.P.)
| | - Octavio M Pontes-Neto
- Department of Neurosciences and Behavioral Sciences, University of Sao Paulo, Ribeirao Preto Medical School, Brazil (O.M.P.-N.)
| | - Stefano Ricci
- Uo Neurologia, USL Umbria 1, Sedi di Citta di Castello e Branca, Italy (S.R.)
| | - Shoichiro Sato
- Department of Cerebrovascular Medicine, National Cerebral and Cardiovascular Center, Suita, Osaka, Japan (S.S.)
| | - Vijay K Sharma
- Yong Loo Lin School of Medicine, National University of Singapore and Division of Neurology, National University Hospital (V.K.S.)
| | - Federico Silva
- Neurovascular Sciences Group, Neurological Institute, Hospital Internacional de Colombia, Bucaramanga (F.S.)
| | - Nguyen H Thang
- Department of Cerebrovascular Disease, The People 115 Hospital, Ho Chi Min, Vietnam (N.H.T.)
| | - Ji-Guang Wang
- Shanghai Institute for Hypertension, Rui Jin Hospital and Shanghai Jiaotong University School of Medicine, China (J.-G.W.)
| | - Mark Woodward
- The George Institute for Global Health, University of New South Wales, Australia (X.W., T.J.M., G.L.D.T., X.C., H.A., C.D., M.W., J.C., L.S., C.S.A).,The George Institute for Global Health, School of Public Health, Imperial College London, United Kingdom (M.W.)
| | - John Chalmers
- The George Institute for Global Health, University of New South Wales, Australia (X.W., T.J.M., G.L.D.T., X.C., H.A., C.D., M.W., J.C., L.S., C.S.A)
| | - Lili Song
- The George Institute for Global Health, University of New South Wales, Australia (X.W., T.J.M., G.L.D.T., X.C., H.A., C.D., M.W., J.C., L.S., C.S.A).,The George Institute China at Peking University Health Sciences Center, Beijing (L.S., C.S.A.)
| | - Craig S Anderson
- The George Institute for Global Health, University of New South Wales, Australia (X.W., T.J.M., G.L.D.T., X.C., H.A., C.D., M.W., J.C., L.S., C.S.A).,Neurology Department, Prince Royal Alfred Hospital, University of Sydney, NSW, Australia. (C.S.A.).,The George Institute China at Peking University Health Sciences Center, Beijing (L.S., C.S.A.)
| | - Thompson G Robinson
- Department of Cardiovascular Sciences, University of Leicester, United Kingdom. (J.S.M., T.G.R.).,National Institute for Health Research Leicester Biomedical Research Centre, United Kingdom (J.S.M., T.G.R.)
| | | |
Collapse
|
36
|
Claassen JAHR, Thijssen DHJ, Panerai RB, Faraci FM. Regulation of cerebral blood flow in humans: physiology and clinical implications of autoregulation. Physiol Rev 2021; 101:1487-1559. [PMID: 33769101 PMCID: PMC8576366 DOI: 10.1152/physrev.00022.2020] [Citation(s) in RCA: 275] [Impact Index Per Article: 91.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
Brain function critically depends on a close matching between metabolic demands, appropriate delivery of oxygen and nutrients, and removal of cellular waste. This matching requires continuous regulation of cerebral blood flow (CBF), which can be categorized into four broad topics: 1) autoregulation, which describes the response of the cerebrovasculature to changes in perfusion pressure; 2) vascular reactivity to vasoactive stimuli [including carbon dioxide (CO2)]; 3) neurovascular coupling (NVC), i.e., the CBF response to local changes in neural activity (often standardized cognitive stimuli in humans); and 4) endothelium-dependent responses. This review focuses primarily on autoregulation and its clinical implications. To place autoregulation in a more precise context, and to better understand integrated approaches in the cerebral circulation, we also briefly address reactivity to CO2 and NVC. In addition to our focus on effects of perfusion pressure (or blood pressure), we describe the impact of select stimuli on regulation of CBF (i.e., arterial blood gases, cerebral metabolism, neural mechanisms, and specific vascular cells), the interrelationships between these stimuli, and implications for regulation of CBF at the level of large arteries and the microcirculation. We review clinical implications of autoregulation in aging, hypertension, stroke, mild cognitive impairment, anesthesia, and dementias. Finally, we discuss autoregulation in the context of common daily physiological challenges, including changes in posture (e.g., orthostatic hypotension, syncope) and physical activity.
Collapse
Affiliation(s)
- Jurgen A H R Claassen
- Department of Geriatrics, Radboud University Medical Center, Donders Institute for Brain, Cognition, and Behaviour, Nijmegen, The Netherlands
| | - Dick H J Thijssen
- Department of Physiology, Radboud Institute for Health Sciences, Nijmegen, The Netherlands
- Research Institute for Sport and Exercise Sciences, Liverpool John Moores University, Liverpool, United Kingdom
| | - Ronney B Panerai
- Department of Cardiovascular Sciences, University of Leicester, Leicester, United Kingdom
- >National Institute for Health Research Leicester Biomedical Research Centre, University of Leicester, Leicester, United Kingdom
| | - Frank M Faraci
- Departments of Internal Medicine, Neuroscience, and Pharmacology, Carver College of Medicine, University of Iowa, Iowa City, Iowa
| |
Collapse
|
37
|
Quinn TJ, Richard E, Teuschl Y, Gattringer T, Hafdi M, O'Brien JT, Merriman N, Gillebert C, Huygelier H, Verdelho A, Schmidt R, Ghaziani E, Forchammer H, Pendlebury ST, Bruffaerts R, Mijajlovic M, Drozdowska BA, Ball E, Markus HS. European Stroke Organisation and European Academy of Neurology joint guidelines on post-stroke cognitive impairment. Eur J Neurol 2021; 28:3883-3920. [PMID: 34476868 DOI: 10.1111/ene.15068] [Citation(s) in RCA: 50] [Impact Index Per Article: 16.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2021] [Accepted: 08/13/2021] [Indexed: 12/14/2022]
Abstract
BACKGROUND AND PURPOSE The optimal management of post-stroke cognitive impairment (PSCI) remains controversial. These joint European Stroke Organisation (ESO) and European Academy of Neurology (EAN) guidelines provide evidence-based recommendations to assist clinicians in decision making regarding prevention, diagnosis, treatment and prognosis. METHODS Guidelines were developed according to the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) methodology. The working group identified relevant clinical questions, performed systematic reviews, assessed the quality of the available evidence, and made specific recommendations. Expert consensus statements were provided where insufficient evidence was available to provide recommendations. RESULTS There was limited randomized controlled trial (RCT) evidence regarding single or multicomponent interventions to prevent post-stroke cognitive decline. Lifestyle interventions and treating vascular risk factors have many health benefits, but a cognitive effect is not proven. We found no evidence regarding routine cognitive screening following stroke, but recognize the importance of targeted cognitive assessment. We describe the accuracy of various cognitive screening tests, but found no clearly superior approach to testing. There was insufficient evidence to make a recommendation for use of cholinesterase inhibitors, memantine nootropics or cognitive rehabilitation. There was limited evidence on the use of prediction tools for post-stroke cognition. The association between PSCI and acute structural brain imaging features was unclear, although the presence of substantial white matter hyperintensities of presumed vascular origin on brain magnetic resonance imaging may help predict cognitive outcomes. CONCLUSIONS These guidelines highlight fundamental areas where robust evidence is lacking. Further definitive RCTs are needed, and we suggest priority areas for future research.
Collapse
Affiliation(s)
- Terence J Quinn
- Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, UK
| | - Edo Richard
- Department of Neurology, Donders Institute for Brain, Behaviour and Cognition, Radboud University Medical Centre, Nijmegen, The Netherlands
| | - Yvonne Teuschl
- Department for Clinical Neurosciences and Preventive Medicine, Danube University Krems, Krems, Austria
| | - Thomas Gattringer
- Department of Neurology and Division of Neuroradiology, Vascular and Interventional Radiology, Department of Radiology, Medical University of Graz, Graz, Austria
| | - Melanie Hafdi
- Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands
| | - John T O'Brien
- Department of Psychiatry, University of Cambridge School of Clinical Medicine, Cambridge, UK
| | - Niamh Merriman
- Department of Health Psychology, Division of Population Health Sciences, Royal College of Surgeons in Ireland, Dublin, Ireland
| | - Celine Gillebert
- Department Brain and Cognition, Leuven Brain Institute, KU Leuven, Leuven, Belgium.,TRACE, Centre for Translational Psychological Research (TRACE), KU Leuven - Hospital East-Limbourgh, Genk, Belgium
| | - Hanne Huygelier
- Department Brain and Cognition, Leuven Brain Institute, KU Leuven, Leuven, Belgium.,TRACE, Centre for Translational Psychological Research (TRACE), KU Leuven - Hospital East-Limbourgh, Genk, Belgium
| | - Ana Verdelho
- Department of Neurosciences and Mental Health, Hospital de Santa Maria, Lisbon, Portugal
| | - Reinhold Schmidt
- Department of Neurology and Medical University of Graz, Graz, Austria
| | - Emma Ghaziani
- Department of Physical and Occupational Therapy, Bispebjerg and Frederiksberg Hospital, Copenhagen, Denmark
| | | | - Sarah T Pendlebury
- Departments of Medicine and Geratology and NIHR Oxford Biomedical Research Centre Oxford University Hospitals NHS Foundation Trust, John Radcliffe Hospital, Oxford, UK
| | - Rose Bruffaerts
- Biomedical Research Institute, Hasselt University, Diepenbeek, Belgium
| | - Milija Mijajlovic
- Neurosonology Unit, Neurology Clinic, University Clinical Center of Serbia and Faculty of Medicine University of Belgrade, Belgrade, Serbia
| | - Bogna A Drozdowska
- Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, UK
| | - Emily Ball
- Centre for Clinical Brain Sciences, University of Edinburgh, Edinburgh, UK
| | - Hugh S Markus
- Stroke Research group, Department of Clinical Neurosciences, University of Cambridge, Cambridge, UK
| |
Collapse
|
38
|
Quinn TJ, Richard E, Teuschl Y, Gattringer T, Hafdi M, O’Brien JT, Merriman N, Gillebert C, Huyglier H, Verdelho A, Schmidt R, Ghaziani E, Forchammer H, Pendlebury ST, Bruffaerts R, Mijajlovic M, Drozdowska BA, Ball E, Markus HS. European Stroke Organisation and European Academy of Neurology joint guidelines on post-stroke cognitive impairment. Eur Stroke J 2021; 6:I-XXXVIII. [PMID: 34746430 PMCID: PMC8564156 DOI: 10.1177/23969873211042192] [Citation(s) in RCA: 24] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2021] [Accepted: 08/09/2021] [Indexed: 01/14/2023] Open
Abstract
The optimal management of post-stroke cognitive impairment remains controversial. These joint European Stroke Organisation (ESO) and European Academy of Neurology (EAN) guidelines provide evidence-based recommendations to assist clinicians in decision making around prevention, diagnosis, treatment and prognosis. These guidelines were developed according to ESO standard operating procedure and the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) methodology. The working group identified relevant clinical questions, performed systematic reviews and, where possible, meta-analyses of the literature, assessed the quality of the available evidence and made specific recommendations. Expert consensus statements were provided where insufficient evidence was available to provide recommendations based on the GRADE approach. There was limited randomised controlled trial evidence regarding single or multicomponent interventions to prevent post-stroke cognitive decline. Interventions to improve lifestyle and treat vascular risk factors may have many health benefits but a beneficial effect on cognition is not proven. We found no evidence around routine cognitive screening following stroke but recognise the importance of targeted cognitive assessment. We described the accuracy of various cognitive screening tests but found no clearly superior approach to testing. There was insufficient evidence to make a recommendation for use of cholinesterase inhibitors, memantine nootropics or cognitive rehabilitation. There was limited evidence on the use of prediction tools for post-stroke cognitive syndromes (cognitive impairment, dementia and delirium). The association between post-stroke cognitive impairment and most acute structural brain imaging features was unclear, although the presence of substantial white matter hyperintensities of presumed vascular origin on acute MRI brain may help predict cognitive outcomes. These guidelines have highlighted fundamental areas where robust evidence is lacking. Further, definitive randomised controlled trials are needed, and we suggest priority areas for future research.
Collapse
Affiliation(s)
- Terence J Quinn
- Institute of Cardiovascular and
Medical Sciences, University of Glasgow, Glasgow, UK
| | - Edo Richard
- Department of Neurology, Donders
Institute for Brain, Behaviour and Cognition, Radboud University Medical
Centre, Nijmegen, The Netherlands
| | - Yvonne Teuschl
- Department for Clinical
Neurosciences and Preventive Medicine, Danube University Krems, der Donau, Austria
| | - Thomas Gattringer
- Department of Neurology and
Division of Neuroradiology, Vascular and Interventional Radiology, Department of
Radiology, Medical University of
Graz, Graz, Austria
| | - Melanie Hafdi
- Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands
| | - John T O’Brien
- Department of Psychiatry, University of Cambridge School of
Clinical Medicine, Cambridge, UK
| | - Niamh Merriman
- Deptartment of Health Psychology,
Division of Population Health Sciences, Royal College of Surgeons in
Ireland, Dublin, Ireland
| | - Celine Gillebert
- Department Brain & Cognition, Leuven Brain Institute, KU Leuven, Leuven, Belgium
- TRACE, Centre for Translational
Psychological Research (TRACE), KU Leuven – Hospital
East-Limbourgh, Genk, Belgium
| | - Hanne Huyglier
- Department Brain & Cognition, Leuven Brain Institute, KU Leuven, Leuven, Belgium
- TRACE, Centre for Translational
Psychological Research (TRACE), KU Leuven – Hospital
East-Limbourgh, Genk, Belgium
| | - Ana Verdelho
- Department of Neurosciences and
Mental Health, Hospital de Santa Maria, Lisbon, Portugal
| | - Reinhold Schmidt
- Department of Neurology, Medical University of
Graz, Graz, Austria
| | - Emma Ghaziani
- Department of Physical and
Occupational Therapy, Bispebjerg and Frederiksberg
Hospital, Copenhagen, Denmark
| | | | - Sarah T Pendlebury
- Departments of Medicine and
Geratology and NIHR Oxford Biomedical Research Centre, John Radcliffe Hospital, Oxford University Hospitals NHS
Foundation Trust, Oxford, UK
| | - Rose Bruffaerts
- Biomedical Research Institute, Hasselt University, Hasselt, Belgium
| | - Milija Mijajlovic
- Neurosonology Unit, Neurology
Clinic, University Clinical Center of Serbia
and Faculty of Medicine University of Belgrade, Belgrade, Serbia
| | - Bogna A Drozdowska
- Institute of Cardiovascular and
Medical Sciences, University of Glasgow, Glasgow, UK
| | - Emily Ball
- Centre for Clinical Brain
Sciences, University of Edinburgh, Edinburgh, Scotland
| | - Hugh S Markus
- Stroke Research Group, Department
of Clinical Neurosciences, University of Cambridge, Cambridge, UK
| |
Collapse
|
39
|
Wardlaw JM, Debette S, Jokinen H, De Leeuw FE, Pantoni L, Chabriat H, Staals J, Doubal F, Rudilosso S, Eppinger S, Schilling S, Ornello R, Enzinger C, Cordonnier C, Taylor-Rowan M, Lindgren AG. ESO Guideline on covert cerebral small vessel disease. Eur Stroke J 2021; 6:CXI-CLXII. [PMID: 34414301 PMCID: PMC8370079 DOI: 10.1177/23969873211012132] [Citation(s) in RCA: 62] [Impact Index Per Article: 20.7] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2021] [Accepted: 04/02/2021] [Indexed: 12/11/2022] Open
Abstract
'Covert' cerebral small vessel disease (ccSVD) is common on neuroimaging in persons without overt neurological manifestations, and increases the risk of future stroke, cognitive impairment, dependency, and death. These European Stroke Organisation (ESO) guidelines provide evidence-based recommendations to assist with clinical decisions about management of ccSVD, specifically white matter hyperintensities and lacunes, to prevent adverse clinical outcomes. The guidelines were developed according to ESO standard operating procedures and Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) methodology. We prioritised the clinical outcomes of stroke, cognitive decline or dementia, dependency, death, mobility and mood disorders, and interventions of blood pressure lowering, antiplatelet drugs, lipid lowering, lifestyle modifications, glucose lowering and conventional treatments for dementia. We systematically reviewed the literature, assessed the evidence, formulated evidence-based recommendations where feasible, and expert consensus statements. We found little direct evidence, mostly of low quality. We recommend patients with ccSVD and hypertension to have their blood pressure well controlled; lower blood pressure targets may reduce ccSVD progression. We do not recommend antiplatelet drugs such as aspirin in ccSVD. We found little evidence on lipid lowering in ccSVD. Smoking cessation is a health priority. We recommend regular exercise which may benefit cognition, and a healthy diet, good sleep habits, avoiding obesity and stress for general health reasons. In ccSVD, we found no evidence for glucose control in the absence of diabetes or for conventional Alzheimer dementia treatments. Randomised controlled trials with clinical endpoints are a priority for ccSVD.
Collapse
Affiliation(s)
- Joanna M Wardlaw
- Centre for Clinical Brain Sciences, UK Dementia Research Institute, University of Edinburgh, Edinburgh, UK
| | - Stephanie Debette
- Bordeaux Population Health Center, University of Bordeaux, INSERM, UM1219, Team VINTAGE
- Department of Neurology, Institute for Neurodegenerative Disease, Bordeaux University Hospital, Bordeaux, France
| | - Hanna Jokinen
- HUS Neurocenter, Division of Neuropsychology, Helsinki University Hospital, University of Helsinki and Department of Psychology and Logopedics, Faculty of Medicine, University of Helsinki, Finland
| | - Frank-Erik De Leeuw
- Radboud University Medical Center, Department of Neurology; Donders Center for Medical Neuroscience, Nijmegen, The Netherlands
| | - Leonardo Pantoni
- Stroke and Dementia Lab, 'Luigi Sacco' Department of Biomedical and Clinical Sciences, University of Milan, Milano, Italy
| | - Hugues Chabriat
- Department of Neurology, Hopital Lariboisiere, APHP, INSERM U 1161, FHU NeuroVasc, University of Paris, Paris, France
| | - Julie Staals
- Department of Neurology, School for Cardiovascular Diseases (CARIM), Maastricht UMC+, AZ Maastricht, the Netherlands
| | - Fergus Doubal
- Centre for Clinical Brain Sciences, UK Dementia Research Institute, University of Edinburgh, Edinburgh, UK
- Dept of Medicine for the Elderly, University of Edinburgh, Edinburgh, UK
| | - Salvatore Rudilosso
- Comprehensive Stroke Center, Department of Neuroscience, Hospital Clínic, Barcelona, Spain
| | - Sebastian Eppinger
- University Clinic of Neurology, Medical University of Graz, Graz, Austria
| | - Sabrina Schilling
- Bordeaux Population Health Center, University of Bordeaux, INSERM, UM1219, Team VINTAGE
| | - Raffaele Ornello
- Department of Applied Clinical Sciences and Biotechnology, University of L’Aquila, L’Aquila, Italy
| | - Christian Enzinger
- University Clinic of Neurology, Medical University of Graz, Graz, Austria
| | - Charlotte Cordonnier
- Univ. Lille, INSERM, CHU Lille, U1172, LilNCog – Lille Neuroscience & Cognition, Lille, France
| | - Martin Taylor-Rowan
- Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, UK
| | - Arne G Lindgren
- Department of Clinical Sciences Lund, Neurology, Lund University; Section of Neurology, Skåne University Hospital, Lund, Sweden
| |
Collapse
|
40
|
Markus HS, Egle M, Croall ID, Sari H, Khan U, Hassan A, Harkness K, MacKinnon A, O'Brien JT, Morris RG, Barrick TR, Blamire AM, Tozer DJ, Ford GA. PRESERVE: Randomized Trial of Intensive Versus Standard Blood Pressure Control in Small Vessel Disease. Stroke 2021; 52:2484-2493. [PMID: 34044580 DOI: 10.1161/strokeaha.120.032054] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
[Figure: see text].
Collapse
Affiliation(s)
- Hugh S Markus
- Stroke Research Group, Department of Clinical Neuroscience, University of Cambridge (H.S.M., M.E., I.D.C., H.S., D.J.T.)
| | - Marco Egle
- Stroke Research Group, Department of Clinical Neuroscience, University of Cambridge (H.S.M., M.E., I.D.C., H.S., D.J.T.)
| | - Iain D Croall
- Stroke Research Group, Department of Clinical Neuroscience, University of Cambridge (H.S.M., M.E., I.D.C., H.S., D.J.T.)
| | - Hasan Sari
- Stroke Research Group, Department of Clinical Neuroscience, University of Cambridge (H.S.M., M.E., I.D.C., H.S., D.J.T.)
| | - Usman Khan
- Atkinson Morley Neuroscience Centre, St. Georges NHS Healthcare Trust (U.K., A.M.)
| | | | | | - Andrew MacKinnon
- Atkinson Morley Neuroscience Centre, St. Georges NHS Healthcare Trust (U.K., A.M.)
| | - John T O'Brien
- Department of Psychiatry, University of Cambridge (J.T.O.)
| | - Robin G Morris
- Kings College Institute of Psychiatry, Psychology and Neurosciences, London, United Kingdom (R.G.M.)
| | - Thomas R Barrick
- Neurosciences Research Centre, Molecular and Clinical Science Research Institute, St George's University of London, United Kingdom (T.R.B.)
| | - Andrew M Blamire
- Magnetic Resonance Centre, Institute of Cellular Medicine, Newcastle University, United Kingdom (A.M.B.)
| | - Daniel J Tozer
- Stroke Research Group, Department of Clinical Neuroscience, University of Cambridge (H.S.M., M.E., I.D.C., H.S., D.J.T.)
| | - Gary A Ford
- Oxford University Hospitals NHS Foundation Trust, University of Oxford (G.A.F.)
| | | |
Collapse
|
41
|
Cunningham EL, Todd SA, Passmore P, Bullock R, McGuinness B. Pharmacological treatment of hypertension in people without prior cerebrovascular disease for the prevention of cognitive impairment and dementia. Cochrane Database Syst Rev 2021; 5:CD004034. [PMID: 34028812 PMCID: PMC8142793 DOI: 10.1002/14651858.cd004034.pub4] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
BACKGROUND This is an update of a Cochrane Review first published in 2006 (McGuinness 2006), and previously updated in 2009 (McGuinness 2009). Hypertension is a risk factor for dementia. Observational studies suggest antihypertensive treatment is associated with lower incidences of cognitive impairment and dementia. There is already clear evidence to support the treatment of hypertension after stroke. OBJECTIVES To assess whether pharmacological treatment of hypertension can prevent cognitive impairment or dementia in people who have no history of cerebrovascular disease. SEARCH METHODS We searched the Specialised Register of the Cochrane Dementia and Cognitive Improvement Group, CENTRAL, MEDLINE, Embase, three other databases, as well as many trials registries and grey literature sources, most recently on 7 July 2020. SELECTION CRITERIA We included randomised controlled trials (RCTs) in which pharmacological interventions to treat hypertension were given for at least 12 months. We excluded trials of pharmacological interventions to lower blood pressure in non-hypertensive participants. We also excluded trials conducted solely in people with stroke. DATA COLLECTION AND ANALYSIS Two authors independently assessed trial quality and extracted data. We contacted study authors for additional information. We collected information regarding incidence of dementia, cognitive decline, change in blood pressure, adverse effects and quality of life. We assessed the certainty of evidence using GRADE. MAIN RESULTS We included 12 studies, totaling 30,412 participants, in this review. Eight studies compared active treatment with placebo. Of the four non-placebo-controlled studies, two compared intensive versus standard blood pressure reduction. The two final included studies compared different classes of antihypertensive drug. Study durations varied from one to five years. The combined result of four placebo-controlled trials that reported incident dementia indicated no evidence of a difference in the risk of dementia between the antihypertensive treatment group and the placebo group (236/7767 versus 259/7660, odds ratio (OR) 0.89, 95% confidence interval (CI) 0.72 to 1.09; very low certainty evidence, downgraded due to study limitations and indirectness). The combined results from five placebo-controlled trials that reported change in Mini-Mental State Examination (MMSE) may indicate a modest benefit from antihypertensive treatment (mean difference (MD) 0.20, 95% CI 0.10 to 0.29; very low certainty evidence, downgraded due to study limitations, indirectness and imprecision). The certainty of evidence for both cognitive outcomes was downgraded on the basis of study limitations and indirectness. Study durations were too short, overall, to expect a significant difference in dementia rates between groups. Dementia and cognitive decline were secondary outcomes for most studies. Additional sources of bias include: the use of antihypertensive medication by the placebo group in the placebo-controlled trials; failure to reach recruitment targets; and early termination of studies on safety grounds. Meta-analysis of the placebo-controlled trials reporting results found a mean change in systolic blood pressure of -9.25 mmHg (95% CI -9.73, -8.78) between treatment (n = 8973) and placebo (n = 8820) groups, and a mean change in diastolic blood pressure of -2.47 mmHg (95% CI -2.70, -2.24) between treatment (n = 7700) and placebo (n = 7509) groups (both low certainty evidence downgraded on the basis of study limitations and inconsistency). Three trials - SHEP 1991, LOMIR MCT IL 1996 and MRC 1996 - reported more withdrawals due to adverse events in active treatment groups than placebo groups. Participants on active treatment in Syst Eur 1998 were less likely to discontinue treatment due to side effects, and participants on active treatment in HYVET 2008 reported fewer 'serious adverse events' than in the placebo group. There was no evidence of a difference in withdrawals rates between groups in SCOPE 2003, and results were unclear for Perez Stable 2000 and Zhang 2018. Heterogeneity precluded meta-analysis. Five of the placebo-controlled trials provided quality of life (QOL) data. Heterogeneity again precluded meta-analysis. SHEP 1991, Syst Eur 1998 and HYVET 2008 reported no evidence of a difference in QOL measures between active treatment and placebo groups over time. The SCOPE 2003 sub-study (Degl'Innocenti 2004) showed a smaller drop in QOL measures in the active treatment compared to the placebo group. LOMIR MCT IL 1996 reported an improvement in a QOL measure at twelve months in one active treatment group and deterioration in another. AUTHORS' CONCLUSIONS High certainty randomised controlled trial evidence regarding the effect of hypertension treatment on dementia and cognitive decline does not yet exist. The studies included in this review provide low certainty evidence (downgraded primarily due to study limitations and indirectness) that pharmacological treatment of hypertension, in people without prior cerebrovascular disease, leads to less cognitive decline compared to controls. This difference is below the level considered clinically significant. The studies included in this review also provide very low certainty evidence that pharmacological treatment of hypertension, in people without prior cerebrovascular disease, prevents dementia.
Collapse
Affiliation(s)
| | - Stephen A Todd
- Care of the Elderly Medicine, Western Health and Social Care Trust, Londonderry, UK
| | - Peter Passmore
- Centre for Public Health, Queen's University Belfast, Belfast, UK
| | - Roger Bullock
- Kingshill Research Centre, Victoria Hospital, Swindon, UK
| | | |
Collapse
|
42
|
Stewart CR, Stringer MS, Shi Y, Thrippleton MJ, Wardlaw JM. Associations Between White Matter Hyperintensity Burden, Cerebral Blood Flow and Transit Time in Small Vessel Disease: An Updated Meta-Analysis. Front Neurol 2021; 12:647848. [PMID: 34017302 PMCID: PMC8129542 DOI: 10.3389/fneur.2021.647848] [Citation(s) in RCA: 43] [Impact Index Per Article: 14.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2020] [Accepted: 04/01/2021] [Indexed: 12/16/2022] Open
Abstract
Cerebral small vessel disease (SVD) is a major contributor to stroke and dementia, characterized by white matter hyperintensities (WMH) on neuroimaging. WMH are associated with reduced cerebral blood flow (CBF) cross-sectionally, though longitudinal associations remain unclear. We updated a 2016 systematic review, identifying 30 new studies, 27 cross-sectional (n = 2,956) and 3 longitudinal (n = 440). Cross-sectionally, 10/27 new studies (n = 1,019) included sufficient data for meta-analysis, which we meta-analyzed with 24 previously reported studies (n = 1,161), total 34 (n = 2,180). Our meta-analysis showed that patients with lower CBF had worse WMH burden (mean global CBF: standardized mean difference (SMD): −0.45, 95% confidence interval (CI): −0.64, −0.27). Longitudinally, associations between baseline CBF and WMH progression varied: the largest study (5 years, n = 252) found no associations, while another small study (4.5 years, n = 52) found that low CBF in the periventricular WMH penumbra predicted WMH progression. We could not meta-analyse longitudinal studies due to different statistical and methodological approaches. We found that CBF was lower in WMH than in normal-appearing white matter in an additional meta-analysis (5 cross-sectional studies; n = 295; SMD: −1.51, 95% CI: −1.94, −1.07). These findings highlight that relationships between resting CBF and WMH are complex. Further longitudinal studies analyzing regional CBF and subsequent WMH change are required to determine the role of CBF in SVD progression.
Collapse
Affiliation(s)
- Catriona R Stewart
- Centre for Clinical Brain Sciences, University of Edinburgh, Edinburgh, United Kingdom
| | - Michael S Stringer
- Centre for Clinical Brain Sciences, University of Edinburgh, Edinburgh, United Kingdom.,UK Dementia Research Institute at the University of Edinburgh, Edinburgh Medical School, Edinburgh, United Kingdom
| | - Yulu Shi
- Beijing Tian Tan Hospital Affiliated to Capital Medical University, Beijing, China
| | - Michael J Thrippleton
- Centre for Clinical Brain Sciences, University of Edinburgh, Edinburgh, United Kingdom.,UK Dementia Research Institute at the University of Edinburgh, Edinburgh Medical School, Edinburgh, United Kingdom
| | - Joanna M Wardlaw
- Centre for Clinical Brain Sciences, University of Edinburgh, Edinburgh, United Kingdom.,UK Dementia Research Institute at the University of Edinburgh, Edinburgh Medical School, Edinburgh, United Kingdom
| |
Collapse
|
43
|
Fernando J, Brown RB, Edwards H, Egle M, Markus HS, Tay J. Individual markers of cerebral small vessel disease and domain-specific quality of life deficits. Brain Behav 2021; 11:e02106. [PMID: 33751852 PMCID: PMC8119866 DOI: 10.1002/brb3.2106] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/22/2020] [Revised: 02/23/2021] [Accepted: 02/24/2021] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Cerebral small vessel disease (SVD) leads to reduced quality of life (QOL), but the mechanisms underlying this relationship remain unknown. This study investigated multivariate relationships between radiological markers of SVD and domain-specific QOL deficits, as well as potential mediators, in patients with SVD. METHODS Clinical and neuroimaging measures were obtained from a pooled sample of 174 SVD patients from the St. George's Cognition and Neuroimaging in Stroke and PRESsure in established cERebral small VEssel disease studies. Lacunes, white matter hyperintensities, and microbleeds were defined as radiological markers of SVD and delineated using MRI. QOL was assessed using the Stroke-Specific Quality of Life Scale. Multivariate linear regression was used to determine whether SVD markers were associated with domain-specific QOL deficits. Significant associations were further investigated using mediation analysis to examine whether functional disability or cognition was potential mediators. RESULTS Multivariate regression analyses revealed that lacunes were associated with total QOL score (β = -8.22, p = .02), as well as reductions in mobility (β = -1.41, p = .008) and language-related subdomains (β = -0.69, p = .033). White matter hyperintensities and microbleeds showed univariate correlations with QOL, but these became nonsignificant during multivariate analyses. Mediation analyses revealed that functional disability, defined as reduced activities of daily living, and executive function, partially mediated the relationship between lacunes and total QOL, as well as mobility-related QOL, but not language-related QOL. CONCLUSIONS Lacunar infarcts have the most detrimental effect on QOL in SVD patients, particularly in the mobility and language-related subdomains. These effects may be partially explained by a reduction in activities of daily living. These results may inform targeted interventions to improve QOL in patients with SVD.
Collapse
Affiliation(s)
- Jeevan Fernando
- Stroke Research GroupDepartment of Clinical NeurosciencesUniversity of CambridgeCambridgeUK
| | - Robin B. Brown
- Stroke Research GroupDepartment of Clinical NeurosciencesUniversity of CambridgeCambridgeUK
| | - Hayley Edwards
- Stroke Research GroupDepartment of Clinical NeurosciencesUniversity of CambridgeCambridgeUK
| | - Marco Egle
- Stroke Research GroupDepartment of Clinical NeurosciencesUniversity of CambridgeCambridgeUK
| | - Hugh S. Markus
- Stroke Research GroupDepartment of Clinical NeurosciencesUniversity of CambridgeCambridgeUK
| | - Jonathan Tay
- Stroke Research GroupDepartment of Clinical NeurosciencesUniversity of CambridgeCambridgeUK
| |
Collapse
|
44
|
Liao YC, Hu YC, Chung CP, Wang YF, Guo YC, Tsai YS, Lee YC. Intracerebral Hemorrhage in Cerebral Autosomal Dominant Arteriopathy With Subcortical Infarcts and Leukoencephalopathy: Prevalence, Clinical and Neuroimaging Features and Risk Factors. Stroke 2021; 52:985-993. [PMID: 33535780 DOI: 10.1161/strokeaha.120.030664] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND AND PURPOSE Cerebral autosomal dominant arteriopathy with subcortical infarcts and leukoencephalopathy (CADASIL) is a monogenic cerebral small vessel disease. The role of intracerebral hemorrhage (ICH) in CADASIL remains elusive. The present study aims to investigate the prevalence, characteristics, and risk factors for ICH in CADASIL. METHODS This retrospective cross-sectional study investigated ICH and cerebral microbleeds (CMBs) in brain susceptibility-weighted imaging or T2*-weighted gradient-recalled echo images of 127 Taiwanese patients with genetically confirmed CADASIL. We analyzed CMBs, lacunes, white matter hyperintensity, and perivascular space. The total small vessel disease score (range, 0-4) was calculated to estimate the overall magnetic resonance imaging burden of small vessel disease. Multivariate regression analysis was performed to identify factors related to ICH lesions in CADASIL. RESULTS Thirty-seven ICH lesions, including 15 symptomatic and 22 asymptomatic lesions, were found in 27 (21.3% [95% CI, 14.0%-30.9%]) of the 127 patients with CADASIL. The thalamus and lobar regions were the most common ICH locations, and 72.7% of the lobar hemorrhages occurred silently. Patients with CADASIL with ICH lesions more often had hypertension and a higher total small vessel disease score than those without ICH (odds ratio [95% CI]: 3.22 [1.25-8.30] and 3.79 [1.51-9.51]). The presence of CMBs in the brain stem and a total CMB count >10 were independently associated with ICH lesions in patients with CADASIL, with odds ratio (95% CI) of 5.82 (1.80-18.80) and 3.83 (1.08-13.67), respectively. CONCLUSIONS ICH is an underestimated but important manifestation of CADASIL. The location and number of CMBs are associated with the presence of ICH lesions in patients with CADASIL.
Collapse
Affiliation(s)
- Yi-Chu Liao
- Department of Neurology, Taipei Veterans General Hospital, Taiwan (Y.-C. Liao., Y.-C.H., C.-P.C., Y.-F.W., Y.-C. Lee.)
- Department of Neurology (Y.-C. Liao., Y.-C.H., C.-P.C., Y.-F.W., Y.-C. Lee), National Yang-Ming University, Taipei, Taiwan
- Brain Research Center (Y.-C. Liao, C.-P.C., Y.-F.W., Y.-C. Lee), National Yang-Ming University, Taipei, Taiwan
| | - Yu-Chen Hu
- Department of Neurology, Taipei Veterans General Hospital, Taiwan (Y.-C. Liao., Y.-C.H., C.-P.C., Y.-F.W., Y.-C. Lee.)
- Department of Neurology (Y.-C. Liao., Y.-C.H., C.-P.C., Y.-F.W., Y.-C. Lee), National Yang-Ming University, Taipei, Taiwan
- Department of Neurology, Sijhih Cathay General Hospital, New Taipei City, Taiwan (Y.-C.H.)
| | - Chih-Ping Chung
- Department of Neurology, Taipei Veterans General Hospital, Taiwan (Y.-C. Liao., Y.-C.H., C.-P.C., Y.-F.W., Y.-C. Lee.)
- Department of Neurology (Y.-C. Liao., Y.-C.H., C.-P.C., Y.-F.W., Y.-C. Lee), National Yang-Ming University, Taipei, Taiwan
- Brain Research Center (Y.-C. Liao, C.-P.C., Y.-F.W., Y.-C. Lee), National Yang-Ming University, Taipei, Taiwan
| | - Yen-Feng Wang
- Department of Neurology, Taipei Veterans General Hospital, Taiwan (Y.-C. Liao., Y.-C.H., C.-P.C., Y.-F.W., Y.-C. Lee.)
- Department of Neurology (Y.-C. Liao., Y.-C.H., C.-P.C., Y.-F.W., Y.-C. Lee), National Yang-Ming University, Taipei, Taiwan
- Brain Research Center (Y.-C. Liao, C.-P.C., Y.-F.W., Y.-C. Lee), National Yang-Ming University, Taipei, Taiwan
| | - Yuh-Cherng Guo
- Institute of Clinical Medicine (Y.-C.G.), National Yang-Ming University, Taipei, Taiwan
- Department of Neurology, China Medical University Hospital, Taichung, Taiwan (Y.-C.G.)
- School of Medicine, College of Medicine, China Medical University, Taichung, Taiwan (Y.-C.G.)
| | - Yu-Shuen Tsai
- Center for Systems and Synthetic Biology (Y.-S.T), National Yang-Ming University, Taipei, Taiwan
| | - Yi-Chung Lee
- Department of Neurology, Taipei Veterans General Hospital, Taiwan (Y.-C. Liao., Y.-C.H., C.-P.C., Y.-F.W., Y.-C. Lee.)
- Department of Neurology (Y.-C. Liao., Y.-C.H., C.-P.C., Y.-F.W., Y.-C. Lee), National Yang-Ming University, Taipei, Taiwan
- Brain Research Center (Y.-C. Liao, C.-P.C., Y.-F.W., Y.-C. Lee), National Yang-Ming University, Taipei, Taiwan
| |
Collapse
|
45
|
Ramakrishnan M, Gronseth G, Gupta A. Blood Pressure Lowering May Decrease Cognitive Decline; But Are We Ready to Lower Blood Pressure in the Real World? JOURNAL OF CLINICAL CARDIOLOGY 2021; 2:34-38. [PMID: 35812169 PMCID: PMC9264545 DOI: 10.33696/cardiology.2.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/15/2023]
Affiliation(s)
- Madhuri Ramakrishnan
- Division of Nephrology and Hypertension, Department of Internal Medicine, University of Kansas Medical Center, Kansas City, Kansas, United States
| | - Gary Gronseth
- Department of Neurology, University of Kansas Medical Center, Kansas City, Kansas, United States
| | - Aditi Gupta
- Division of Nephrology and Hypertension, Department of Internal Medicine, University of Kansas Medical Center, Kansas City, Kansas, United States
- Department of Neurology, University of Kansas Medical Center, Kansas City, Kansas, United States
- Alzheimer’s Disease Center, University of Kansas Medical Center, Kansas City, Kansas, United States
| |
Collapse
|
46
|
Eldin AESAMT, Bahnasy WS, Dabees NL, Fayed HAER. Cognitive and balance impairments in people with incidental white matter hyperintensities. THE EGYPTIAN JOURNAL OF NEUROLOGY, PSYCHIATRY AND NEUROSURGERY 2020. [DOI: 10.1186/s41983-020-00228-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
Abstract
Background
White matter hyperintensities (WMHs) is the most frequent type of cerebral small vessel diseases and a common incidental finding in MRI films of the geriatric population. The objectives of this work were to study the existence of occult cognitive and balance impairments in subjects with accidentally discovered WMHs.
Methods
The study was conducted on 44 subjects with accidentally discovered WMHs and 24 non-WMHs subjects submitted to the advanced activity of daily living scale (AADLs), a neurocognitive battery assessing different cognitive domains, Berg balance test (BBT), computerized dynamic posturography (CDP), and brain MRI diffusion tensor tractography (DTT).
Results
WMHs subjects showed a significant decrease in AADLs as well as visual and vestibular ratios of CDP. Regarding the neurocognitive battery, there were significant decreases in MoCA as well as arithmetic test and block design of Wechsler adult intelligence scale-IV in WMHs compared to non-WMHs subjects’ groups (p value < 0.001). Concerning Wisconsin Card Sorting subtests, each preservative response, preservative errors, non-preservative errors and trials to complete the 1st category showed a highly significant increase in WMHs compared to non-WMHs subjects (p values < 0.001). DTT showed a substantial reduction in fractional anisotropy (FA) of each corticospinal tract, thalamocortical connectivity, and arcuate fasciculi.
Conclusion
Subjects with WMHs have lower cognitive performance and subtle balance impairment which greatly impair their ADLs.
Collapse
|
47
|
Abstract
Hypertension is a well-established and modifiable risk factor for stroke and other cardiovascular diseases. Notably, stroke is the second leading cause of death worldwide and the second most common cause of disability-adjusted life-years. As such, we provide a viewpoint on blood pressure management in stroke and emphasize blood pressure control or management for first and recurrent stroke prevention, acute stroke treatment, and for prevention of cognitive impairment or dementia.
Collapse
Affiliation(s)
- Philip B Gorelick
- From the Division of Stroke and Neurocritical Care, Davee Department of Neurology (P.B.G.), Northwestern University Feinberg School of Medicine, Chicago, IL
| | - Paul K Whelton
- Department of Epidemiology, Tulane University School of Public Health and Tropical Medicine, Tulane University of Medicine, New Orleans, LA (P.K.W.)
| | - Farzaneh Sorond
- Davee Department of Neurology (F.S.), Northwestern University Feinberg School of Medicine, Chicago, IL
| | - Robert M Carey
- Division of Endocrinology and Metabolism, Department of Medicine, Dean Emeritus, School of Medicine, University of Virginia Health System, Charlottesville (R.M.C.)
| |
Collapse
|
48
|
Gupta A, Perdomo S, Billinger S, Beddhu S, Burns J, Gronseth G. Treatment of hypertension reduces cognitive decline in older adults: a systematic review and meta-analysis. BMJ Open 2020; 10:e038971. [PMID: 33203630 PMCID: PMC7674095 DOI: 10.1136/bmjopen-2020-038971] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
OBJECTIVES To systematically analyse the effect of pharmacological treatment of hypertension (HTN) on cognitive decline in older adults. METHODS Randomised, placebo-controlled trials with a prespecified quantitative outcome of cognition and a pharmacological intervention for at least 12 months to treat HTN in older adults (>60 years). Our primary outcome was change in cognition with pharmacological treatment of HTN. Standardised mean difference (SMD) was used to analyse different outcomes reported in the selected studies. We searched PubMed CENTRAL and the Cochrane Library from inception to 6 July 2020. Two independent reviewers assessed trial quality and extracted data. Internal and external validity of the studies was assessed. RESULTS Nine randomised controlled trials with 34 994 participants were included in the final analysis. The net SMD for change in cognition was -0.049 (CI: -0.078 to -0.019) indicating that treatment of HTN decreased cognitive decline. Heterogeneity was low with an I² of 6%. DISCUSSION Current evidence does not indicate worsening of cognition with treatment of HTN. Treatment of HTN in older adults may reduce cognitive decline. These results have important implications in clinical management of patients at risk for dementia. PROSPERO REGISTRATION NUMBER CRD42020139750.
Collapse
Affiliation(s)
- Aditi Gupta
- Division of Nephrology and Hypertension, Department of Internal Medicine, University of Kansas Medical Center, Kansas City, Kansas, USA
- Alzheimer's Disease Center, University of Kansas Medical Center, Kansas City, Kansas, USA
| | - Sophy Perdomo
- Department of Physical Therapy and Rehabilitation Science, University of Kansas Medical Center, Kansas City, Kansas, USA
| | - Sandra Billinger
- Department of Physical Therapy and Rehabilitation Science, University of Kansas Medical Center, Kansas City, Kansas, USA
- Department of Neurology, University of Kansas Medical Center, Kansas City, Kansas, USA
| | - Srinivasan Beddhu
- Division of Nephrology and Hypertension, University of Utah, Salt Lake City, Utah, USA
| | - Jeffrey Burns
- Alzheimer's Disease Center, University of Kansas Medical Center, Kansas City, Kansas, USA
- Department of Neurology, University of Kansas Medical Center, Kansas City, Kansas, USA
| | - Gary Gronseth
- Department of Neurology, University of Kansas Medical Center, Kansas City, Kansas, USA
| |
Collapse
|
49
|
Abstract
ABSTRACT Cerebral small vessel disease (SVD) is a common global brain disease that causes cognitive impairment, ischemic or hemorrhagic stroke, problems with mobility, and neuropsychiatric symptoms. The brain damage, seen as focal white and deep grey matter lesions on brain magnetic resonance imaging (MRI) or computed tomography (CT), typically accumulates "covertly" and may reach an advanced state before being detected incidentally on brain scanning or causing symptoms. Patients have typically presented to different clinical services or been recruited into research focused on one clinical manifestation, perhaps explaining a lack of awareness, until recently, of the full range and complexity of SVD.In this review, we discuss the varied clinical presentations, established and emerging risk factors, relationship to SVD features on MRI or CT, and the current state of knowledge on the effectiveness of a wide range of pharmacological and lifestyle interventions. The core message is that effective assessment and clinical management of patients with SVD, as well as future advances in diagnosis, care, and treatment, will require a more "joined-up"' approach. This approach should integrate clinical expertise in stroke neurology, cognitive, and physical dysfunctions. It requires more clinical trials in order to improve pharmacological interventions, lifestyle and dietary modifications. A deeper understanding of the pathophysiology of SVD is required to steer the identification of novel interventions. An essential prerequisite to accelerating clinical trials is to improve the consistency, and standardization of clinical, cognitive and neuroimaging endpoints.
Collapse
|
50
|
Lai Y, Jiang C, Du X, Sang C, Guo X, Bai R, Tang R, Dong J, Ma C. Effect of intensive blood pressure control on the prevention of white matter hyperintensity: Systematic review and meta‐analysis of randomized trials. J Clin Hypertens (Greenwich) 2020; 22:1968-1973. [PMID: 33459521 DOI: 10.1111/jch.14030] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2020] [Revised: 08/13/2020] [Accepted: 08/17/2020] [Indexed: 12/27/2022]
Affiliation(s)
- Yiwei Lai
- Department of Cardiology Beijing Anzhen Hospital Beijing China
- Capital Medical University National Clinical Research Centre for Cardiovascular Diseases Beijing China
- Beijing Advanced Innovation Center for Big Data‐Based Precision Medicine for Cardiovascular Diseases Beijing China
| | - Chao Jiang
- Department of Cardiology Beijing Anzhen Hospital Beijing China
- Capital Medical University National Clinical Research Centre for Cardiovascular Diseases Beijing China
- Beijing Advanced Innovation Center for Big Data‐Based Precision Medicine for Cardiovascular Diseases Beijing China
| | - Xin Du
- Department of Cardiology Beijing Anzhen Hospital Beijing China
- Capital Medical University National Clinical Research Centre for Cardiovascular Diseases Beijing China
- Beijing Advanced Innovation Center for Big Data‐Based Precision Medicine for Cardiovascular Diseases Beijing China
| | - Caihua Sang
- Department of Cardiology Beijing Anzhen Hospital Beijing China
- Capital Medical University National Clinical Research Centre for Cardiovascular Diseases Beijing China
- Beijing Advanced Innovation Center for Big Data‐Based Precision Medicine for Cardiovascular Diseases Beijing China
| | - Xueyuan Guo
- Department of Cardiology Beijing Anzhen Hospital Beijing China
- Capital Medical University National Clinical Research Centre for Cardiovascular Diseases Beijing China
- Beijing Advanced Innovation Center for Big Data‐Based Precision Medicine for Cardiovascular Diseases Beijing China
| | - Rong Bai
- Department of Cardiology Beijing Anzhen Hospital Beijing China
- Capital Medical University National Clinical Research Centre for Cardiovascular Diseases Beijing China
- Beijing Advanced Innovation Center for Big Data‐Based Precision Medicine for Cardiovascular Diseases Beijing China
| | - Ribo Tang
- Department of Cardiology Beijing Anzhen Hospital Beijing China
- Capital Medical University National Clinical Research Centre for Cardiovascular Diseases Beijing China
- Beijing Advanced Innovation Center for Big Data‐Based Precision Medicine for Cardiovascular Diseases Beijing China
| | - Jianzeng Dong
- Department of Cardiology Beijing Anzhen Hospital Beijing China
- Capital Medical University National Clinical Research Centre for Cardiovascular Diseases Beijing China
- Beijing Advanced Innovation Center for Big Data‐Based Precision Medicine for Cardiovascular Diseases Beijing China
| | - Changsheng Ma
- Department of Cardiology Beijing Anzhen Hospital Beijing China
- Capital Medical University National Clinical Research Centre for Cardiovascular Diseases Beijing China
- Beijing Advanced Innovation Center for Big Data‐Based Precision Medicine for Cardiovascular Diseases Beijing China
| |
Collapse
|