Small subcortical infarcts and primary subcortical haemorrhages may have different risk factors

Differential risk factor profile and neuroimaging markers of small vessel disease between lacunar ischemic stroke and deep intracerebral hemorrhage

Background

Lacunar ischemic stroke (LIS) and deep intracerebral hemorrhage (dICH) are two stroke phenotypes of deep perforator arteriopathy. It is unclear what factors predispose individuals with deep perforator arteriopathy to either ischemic or hemorrhagic events.

Objectives

We aimed to investigate risk factors and neuroimaging features of small vessel disease (SVD) associated with LIS versus dICH in a cross-sectional study.

Methods

We included patients with clinically presenting, magnetic resonance imaging-confirmed LIS or dICH from two tertiary hospitals between 2010 and 2021. We recorded vascular risk factors and SVD markers, including lacunes, white matter hyperintensities (WMH), perivascular spaces (PVS), and cerebral microbleeds (CMB). Logistic regression modeling was used to determine the association between vascular risk factors, SVD markers, and stroke phenotype. We further created WMH probability maps to compare WMH distribution between LIS and dICH.

Results

A total of 834 patients with LIS (mean age 61.7 ± 12.1 years) and 405 with dICH (57.7 ± 13.2 years) were included. Hypertension was equally frequent between LIS and dICH (72.3% versus 74.8%, p = 0.349). Diabetes mellitus, hyperlipidemia, smoking, and prior ischemic stroke were more associated with LIS [odds ratio (OR) (95% confidence interval (CI)), 0.35 (0.25-0.48), 0.32 (0.22-0.44), 0.31 (0.22-0.44), and 0.38 (0.18-0.75)]. Alcohol intake and prior ICH were more associated with dICH [OR (95% CI), 2.34 (1.68-3.28), 2.53 (1.31-4.92)]. Lacunes were more prevalent in LIS [OR (95% CI) 0.23 (0.11-0.43)], while moderate-to-severe basal-ganglia PVS and CMB were more prevalent in dICH [OR (95% CI) 2.63 (1.35-5.27), 4.95 (2.71-9.42)]. WMH burden and spatial distribution did not differ between groups.

Conclusion

The microangiopathy underlying LIS and dICH reflects distinct risk profiles and SVD features, hence possibly SVD subtype susceptibility. Prospective studies with careful phenotyping and genetics are needed to clarify the mechanisms underlying this difference.

Alcohol Consumption Increases Post-Operative Infection but Not Mortality: A Systematic Review and Meta-Analysis

BACKGROUND

Alcohol consumption causes multiple comorbidities with potentially negative outcome after operations. The aims are to study the association between alcohol consumption and post-operative non-surgical site infections and mortality and to determine the impact of peri-operative interventions.

METHODS

MEDLINE, Embase, and The Cochrane Library were searched systematically. Observational studies reporting patients with a defined amount of alcohol consumption and randomized controlled trials (RCTs) aimed at reducing outcomes were included. Meta-analyses were performed separately for observational studies and RCTs.

RESULTS

Thirteen observational studies and five RCTs were identified. Meta-analyses of observational studies showed more infections in those consuming more than two units of alcohol per day compared with drinking less in both unadjusted and adjusted data. No association between alcohol consumption and mortality was found. Meta-analyses of RCTs showed that interventions reduce infections but not mortality in patients with alcohol abuse.

CONCLUSIONS

Consumption of more than two units of alcohol per day increases post-operative non-surgical site infections. Alcohol-refraining interventions in patients with high daily alcohol consumption appear to reduce infections. The impact in patients with lesser intake is unknown. Further studies are needed.

Alcohol drinking does not affect postoperative surgical site infection or anastomotic leakage: a systematic review and meta-analysis

BACKGROUND

Alcohol abuse appears to increase postoperative complications, but clinical trials have reported conflicting results. The objective of this systematic review and meta-analysis is to clarify how alcohol drinking affects postoperative surgical site infection and anastomotic leakage and to determine the impact of perioperative alcohol intervention.

MATERIAL AND METHODS

The databases MEDLINE, EMBASE, and CENTRAL were searched. Observational studies assessing surgical site infection and anastomotic leakage for alcohol drinkers and randomized controlled trials (RCTs) studying perioperative alcohol interventions were included. Meta-analyses were performed with random effects models. Methodological quality was assessed by the Newcastle-Ottawa Scale and Cochrane methodology.

RESULTS

Fifteen observational studies and 2 RCTs were identified. Meta-analyses were performed for alcohol drinkers vs nondrinkers and moderate drinkers (≤ 2 U/day), respectively. No difference between alcohol drinkers and nondrinkers was found. When drinkers and moderate drinkers were compared, a significantly higher incidence of surgical site infection and anastomotic leakage was found in unadjusted studies. In the meta-analysis of studies adjusting for smoking and age, alcohol drinking did not significantly affect surgical site infection and anastomotic leakage. The RCTs did not show any effect of perioperative alcohol abstinence or pharmacological withdrawal treatment on outcome.

CONCLUSIONS

Alcohol drinking is not an independent risk factor for surgical site infection and anastomotic leakage. Interventions which aim to make patients quit alcohol or treat withdrawal symptoms do not seem to affect the surgical outcomes of interest.

Differences in left ventricular hypertrophy and dysfunction between patients with cerebral hemorrhage and those with cerebral infarction

Left ventricular (LV) hypertrophy and dysfunction due to hypertension have been established as risk markers for stroke in hypertensive patients. The purpose of this study was to examine the differences in LV hypertrophy and dysfunction between patients with cerebral hemorrhage and those with cerebral infarction. The study enrolled 23 hypertensive patients with cerebral infarction, 25 hypertensive patients with cerebral hemorrhage, and 24 normotensive controls (controls). Standard echocardiography was performed; LV mass index was measured to evaluate LV hypertrophy, and conventional diastolic transmitral flow velocities were measured to assess LV diastolic function, which was also evaluated by measuring mitral annular velocities using tissue Doppler echocardiography. The Tei index, which reflects both the diastolic and systolic function of LV, was also calculated. The LV mass index and Tei index were significantly higher in cerebral hemorrhage (116 +/- 38 g/m(2) and 0.57 +/- 0.13) than those in controls (92 +/- 20 g/m(2) and 0.46 +/- 0.10) (p < 0.05). In contrast, the LV mass index and Tei index in cerebral infarction (100 +/- 27 g/m(2) and 0.46 +/- 0.12) were not different from those in controls. Thus, the Tei index was significantly worse in the patients with cerebral hemorrhage than in those with cerebral infarction (p < 0.05). On the other hand, the parameters, which reflect diastolic function, showed no significant differences between cerebral hemorrhage and cerebral infarction. These results indicate that LV hypertrophy and dysfunction due to hypertension are more apparent in patients with cerebral hemorrhage than in those with cerebral infarction.

A polymorphism of the aldehyde dehydrogenase 2 gene is a risk factor for multiple lacunar infarcts in Japanese men: the Takahata Study

The objective of the present study was to examine the association between a polymorphism of the aldehyde dehydrogenase 2 (ALDH2) gene and lacunar infarcts of the brain. We conducted a population-based, cross-sectional study on residents from two age groups (61- and 72-year olds). A total of 376 subjects participated in the study, which included brain magnetic resonance image and genetic analysis of the ALDH2 gene. Of the 61- and 72-year-old subjects, 46.4% and 64.3%, respectively, had one or more lacunar infarcts. The average number of infarcts also increased from 2.0 to 2.8 in men and from 2.3 to 3.5 in women. No significant association between the ALDH2 genotype and the presence of lacunar infarction (> or =1) was found. However, in subjects with lacunar infarction, the genotype of ALDH2 *1/*1 was associated with a larger number of the lesion ['single' versus 'multiple' odds ratio (OR) 3.73, 95%CI: 1.43-9.74] in men. The OR was comparable even after adjusting for alcohol consumption, tobacco habits, age, hypertension, hypercholesterolemia, and diabetes mellitus (DM) (OR 3.88; 95% CI: 1.10-13.66). In women, there was no significant association between the ALDH2 genotypes and lacunar infarcts. The present study revealed that the ALDH2 *1/*1 genotype was significantly associated with the prevalence of multiple lacunar infarcts in Japanese men.

Small vessel strokes

Small vessel disease is a common cause of cerebrovascular disease. It is responsible for ischemic and hemorrhagic strokes, cognitive decline, and asymptomatic disease. Millions of Americans are affected by silent strokes and white matter abnormalities. Lacunar stroke is the most common manifestation. Despite its importance, small vessel strokes remain understudied. There is a need for research focused on this prevalent stroke subtype to define optimal interventions to prevent stroke recurrence and cognitive impairment.

Common carotid artery intima-media thickness for the risk assessment of lacunar infarction versus intracerebral haemorrhage

BACKGROUND AND PURPOSE

Arterial hypertension is the major risk factor for intracerebral haemorrhage (ICH) and lacunar infarction (LI) and both types of cerebral lesions originate from pathology of the same deep perforating small arteries. We aimed to evaluate the relationship between vascular risk factors including common carotid artery intima-media thickness (CCA-IMT) with LI versus ICH.

METHODS

We prospectively collected data from 159 first ever stroke patients (67 cases with ICH and 92 cases with LI) with documented history of hypertension. All subjects underwent B-mode ultrasonographic measurements of the CCA-IMT. Logistic regression modelling was used to determine the factors (established vascular risk factors, severity and duration of hypertension, concomitant medications and CCA-IMT) that may significantly differentiate LI from ICH.

RESULTS

Patients with LI had significantly (p=0.002) larger CCA-IMT values (0.926 mm, 95% CI: 0.881-0.971) than subjects with ICH (0.815 mm, 95% CI: 0.762-0.868) even after adjusting for baseline characteristics and cardiovascular medications. The multivariate logistic regression procedure selected CCA-IMT, diabetes mellitus and hypercholesterolaemia as the only independent factors able to discriminate between LI and ICH. The risk for LI versus ICH increased continuously with increasing CCA-IMT. For each increment of 0.1 mm in CCA-IMT the probability of suffering from LI versus ICH increased by 36.6% (95 % CI: 13%-65.2%, p=0.001) even after adjustment for cardiovascular risk factors.

CONCLUSIONS

Increased CCA-IMT values are a factor favouring LI over ICH in hypertensive patients. The measurement of CCA-IMT may be a useful non-invasive diagnostic tool for the risk assessment of LI with respect to ICH in such patients.

Insulin resistance: a metabolic link between depressive disorder and atherosclerotic vascular diseases

The association of depression with insulin resistance (IR) and athersclerotic vascular diseases has been well documented. This review examines the relevance of IR as a link between depressive disorder and atherosclerotic vascular diseases. Relevant articles collected from Medline database over the period of 1966-2001 were reviewed. Studies have shown that IR is a state-dependent abnormality in depression and depression increases the risk of vascular morbidity and mortality. Given that IR is a central component of cardiovascular risk factors, depression-related IR might play a role in the development and progression of coronary and cerebral atherosclerosis in chronic-resistant depression. Further, IR may contribute to the pathophysiology of depressive disorder. In conclusion IR could account for the linkage between depression and atherosclerotic vascular diseases. More studies are needed to examine the importance of improving insulin sensitivity in the treatment of chronic-resistant depression and prevention of depression-related vascular morbidity and mortality.