Computed tomography evaluation of intracranial atherosclerosis in Chinese patients with transient ischemic attack or minor ischemic stroke--its distribution and association with vascular risk factors

Carotid atherosclerotic plaque predicts progression of intracranial artery atherosclerosis: A MR imaging-based community cohort study

PURPOSE

Intracranial artery atherosclerosis (ICAS) progression is associated with stroke. However, the association of carotid plaque with ICAS progression among stroke-free participants is still unclear. This study aimed to evaluate the association between carotid plaque and ICAS progression in stroke-free participants.

METHOD

Stroke-free participants were recruited from a community-based cohort study. All participants underwent questionnaire interviews, blood tests, and high-resolution vessel wall magnetic resonance (MR) imaging at baseline and follow-up for around three years. The atherosclerotic plaque was defined as eccentric wall thickening on MR imaging. The presence, location, total number, and burden (maximum wall thickness, length, and stenosis) of carotid and intracranial plaque were evaluated. ICAS progression was defined as the number increased or plaque burden (maximum wall thickness, length, or stenosis increase) increased by ≥ 20 %. The association between carotid plaque and ICAS progression was evaluated using multivariable logistic regression.

RESULTS

Of the 312 participants (mean age at baseline: 59.85 ± 13.04 years; 136 males) who completed baseline and follow-up studies with a mean time interval of 3.15 ± 0.59 years, 85 (27.24 %) had progression of ICAS during follow-up. At least one carotid plaque was detected at baseline in 167 (53.53 %) participants. In the multivariable logistic analysis, carotid plaque was a significant predictor for the progression of ICAS (odds ratio, 2.04; 95 % confidence interval, 1.06-3.92; P = 0.032).

CONCLUSIONS

Carotid plaque is associated with intracranial artery atherosclerosis progression in stroke-free population. Our findings suggest that carotid plaque may be an effective predictor for intracranial artery atherosclerosis progression.

Risk factors associated with hemorrhagic cerebrovascular accident: A cross-sectional study in patients from a hospital in Peru

In Peru, cardiovascular accidents (CVA) cause around 15% of premature death, with an increase in CVA due to the prevalence of risk factors for CVA in the Peruvian population. Hemorrhagic CVA presents higher mortality compared to ischemic. This research aimed to identify the risk factors associated with hemorrhagic CVA. We carried out a retrospective cross-sectional study using the medical records of patients with a diagnosis of CVA treated at the Regional Hospital of Ica during the years 2018 and 2019. Independent variables included age, sex, type 2 diabetes, dyslipidemia, hypertension, smoking, obesity, and intracranial carotid artery calcification. To identify factors associated with an increased probability for hemorrhagic CVA compared to ischemic CVA, a generalized linear model with logit link and binomial family, obtaining the odds ratio (OR) and its 95% confidence interval (CI). we evaluated the data from 132 patients. Of them, 46 (34.85%) had hemorrhagic CVA. Only systolic blood pressure (OR: 1.04; 95% CI: 1.02-1.06) and hypertension (OR: 0.29; 95% CI: 0.10-0.89) were significantly associated with hemorrhagic CVA compared to ischemic CVA. Hypertension is associated with hemorrhagic CVA compared to ischemic CVA. These results are consistent with the literature.

Brachial-ankle pulse wave velocity is associated with intracranial artery calcification in acute stroke patients

BACKGROUND

Intracranial artery calcification (IAC) is closely associated with cerebrovascular disease. Brachial-ankle pulse wave velocity (baPWV) is a noninvasive method for estimating arterial stiffness, which reflects the stiffness of peripheral arteries. This study aimed to examine the association of baPWV with the presence and degree of IAC in patients with acute ischemic stroke.

METHODS

A total of 143 ischemic stroke subjects were recruited. A head computed tomography (CT) scan was used to assess the presence and severity of IAC. The oscillometric method was used to simultaneously measure bilateral brachial and posterior tibial arterial pulse waveforms and arterial BP. Multiple logistic regression analysis was used to identify the independent relationship between baPWV and IAC.

RESULTS

143 subjects were included in this study. The demographic and clinical characteristics of the study population were classified according to the baPWV quartile. A higher prevalence of IAC was noted across increasing baPWV quartiles (Q1: 53 %, Q2: 69 %, Q3: 86 %, Q4: 94 %, P < 0.001). IAC scores were also increased with elevated ccPWV values (1.60 ± 1.71; 2.56 ± 1.99; 3.44 ± 1.91; 4.64 ± 1.58. P < 0.001). After an additional adjustment for age and hypertension, the odds ratio (95 % confidence interval) for the IAC scores was 1.61 (1.06-2.45; P = 0.025) in the top quartile of baPWV compared with those in the lowest quartile.

CONCLUSIONS

Arterial stiffness as defined by baPWV was positively associated with the degree of IAC in patients with acute ischemic stroke, suggesting the severity of IAC may also be a marker of peripheral or systemic arterial stiffness.

Correlation Between Intracranial Calcification and Extracranial Stenosis of the Internal Carotid Artery

Intracranial artery calcification is a marker of vascular atherosclerosis and has a high prevalence worldwide. Both atherosclerosis of the internal carotid artery at the carotid sinus in the neck and intracranial calcification have been associated with ischemic stroke. The relationship between the two has not been well studied. The present study investigated how carotid sinus narrowing could relate to calcification located in the distal intracranial artery at the cavernous carotid. We examined a population not selected for cerebral disease. This retrospective study contained 179 subjects aged 18 years and older from the Hawaii Diagnostic Radiology database. Extracranial internal carotid artery stenosis was determined using the absolute diameter, North American Symptomatic Carotid Endarterectomy Trial, and common carotid artery methods. Calcification was scored using the modified Woodcock method. A positive correlation between intracranial calcification and extracranial carotid stenosis was found using all three methods. Individuals with intracranial calcification were more likely to be older, have a smaller internal carotid artery diameter, and have a greater percent stenosis at the internal carotid artery than those without intracranial artery calcification (p<0.001 for all). These results may help refocus interest in calcification in studies of cerebral vasculature and its correlation with extracranial carotid stenosis.

ATHEROMATOSIS OF THE BRAIN-SUPPLYING ARTERIES: CIRCLE OF WILLIS, BASILAR, VERTEBRAL AND THEIR BRANCHES

PURPOSE

Atherosclerotic plaques in the brain-supplying arteries are slowly-developing alterations of vascular structures that can lead to neurological impairment due to stenosis and insufficient oxygenation of eloquent brain areas. The aim of this study is to provide detailed demographic information related to the incidence of atherosclerotic plaques in the cerebral arteries.

MATERIAL AND METHODS

Forty-eight circles of Willis (21 men, 21 women, mean age: 70.26, six samples unknown) were macroscopically analyzed for length, diameter, and presence of atherosclerotic plaques. Statistical analysis was used to identify potential differences in the locations and frequencies of atherosclerotic plaques in relation to age and sex.

RESULTS

The study sample revealed 261 atherosclerotic plaques. The key findings were significant correlations between plaque development and age and between plaque location and age; however, there was no significant sex difference.

CONCLUSION

The upper and lower branches of the middle cerebral artery (MCA) were novel locations predisposing to plaque development. A cut-off value at 60 years revealed a significant difference in plaque development and distribution. There were no significant sex differences in the occurrence of atherosclerotic plaques.

Histology-Verified Intracranial Artery Calcification and Its Clinical Relevance With Cerebrovascular Disease

Intracranial artery calcification (IAC) was regarded as a proxy for intracranial atherosclerosis (ICAS). IAC could be easily detected on routine computer tomography (CT), which was neglected by clinicians in the previous years. The evolution of advanced imaging technologies, especially vessel wall scanning using high resolution-magnetic resonance imaging (HR-MRI), has aroused the interest of researchers to further explore the characteristics and clinical impacts of IAC. Recent histological evidence acquired from the human cerebral artery specimens demonstrated that IAC could mainly involve two layers: the intima and the media. Accumulating evidence from histological and clinical imaging studies verified that intimal calcification is more associated with ICAS, while medial calcification, especially the internal elastic lamina, contributes to arterial stiffness rather than ICAS. Considering the highly improved abilities of novel imaging technologies in differentiating intimal and medial calcification within the large intracranial arteries, this review aimed to describe the histological and imaging features of two types of IAC, as well as the risk factors, the hemodynamic influences, and other clinical impacts of IAC occurring in intimal or media layers.

Carotid Artery Calcification: What We Know So Far

Carotid artery calcification (CAC) is a well-known marker of atherosclerosis and is linked to a high rate of morbidity and mortality. CAC is divided into two types: intimal and medial calcifications, each with its own set of risk factors. Vascular calcification is now understood to be an active, enzymatically regulated process involving dystrophic calcification and endothelial dysfunction at an early stage. This causes a pathogenic inflammatory response, resulting in calcium phosphate deposition in the form of microcalcifications, which causes plaque formation, ultimately becoming unstable with sequelae of complications. If the inflammation goes away, hydroxyapatite crystal formation takes over, resulting in macro-calcifications that help to keep the plaque stable. As CAC can be asymptomatic, it is critical to identify it early using diagnostic imaging. The carotid artery calcification score is calculated using computed tomography angiography (CTA), which is a confirmatory test that enables the examination of plaque composition and computation of the carotid artery calcification score. Magnetic resonance angiography (MRA), which is sensitive as CTA, duplex ultrasound (DUS), positron emission tomography, and computed tomography (PET-CT) imaging with (18) F-Sodium Fluoride, and Optical Coherence Tomography (OCT) are some of the other diagnostic imaging modalities used. The current therapeutic method starts with the best medical care and is advised for all CAC patients. Carotid endarterectomy and carotid stenting are two treatment options that have mixed results in terms of effectiveness and safety. When patient age and anatomy, operator expertise, and surgical risk are all considered, the agreement is that both techniques are equally beneficial.

Intracranial Arterial Calcification: Prevalence, Risk Factors, and Consequences: JACC Review Topic of the Week

Intracranial large and small arterial calcifications are a common incidental finding on computed tomography imaging in the general population. Here we provide an overview of the published reports on prevalence of intracranial arterial calcifications on computed tomography imaging and histopathology in relation to risk factors and clinical outcomes. We performed a systematic search in Medline, with a search filter using synonyms for computed tomography scanning, (histo)pathology, different intracranial arterial beds, and calcification. We found that intracranial calcifications are a frequent finding in all arterial beds with the highest prevalence in the intracranial internal carotid artery. In general, prevalence increases with age. Longitudinal studies on calcification progression and intervention studies are warranted to investigate the possible causal role of calcification on clinical outcomes. This might open up new therapeutic directions in stroke and dementia prevention and the maintenance of the healthy brain.

Intracranial Arterial Calcification Relates to Long-Term Risk of Recurrent Stroke and Post-stroke Mortality

Background: Intracranial arterial calcification (IAC) is highly prevalent in ischemic stroke patients. However, data on the association of IAC with stroke recurrence and mortality remains limited. We examined the effect of IAC on the long-term recurrence of stroke and the risk of post-stroke mortality.

Methods: Using a prospective stroke registry, we recruited 694 patients (mean age 71.6 ± 12.4; male sex 50.3%) since December 2004. IAC was visualized using the computed tomography exam that was made at hospital admission and was quantified with the Agatston method. All patients were regularly followed up till July 2016. The impacts of IAC on stroke recurrence and mortality were assessed using Cox-regression models with adjustments for age, sex, and relevant cardiovascular risk factors.

Results: During a median follow-up period of 8.8 years, 156 patients (22.5%) suffered a recurrent stroke and 84 died (12.1%). We found that a higher IAC Agatston score related to a higher risk of stroke recurrence (HR per 1-SD increase in IAC: 1.30; 95% CI, 1.08–1.56, p = 0.005) and a higher risk of post-stroke mortality (HR per 1-SD increase, 1.44; 95% CI, 1.06–1.96, p = 0.019). After investigating etiology-specific risks of stroke-recurrence, we found that a higher IAC Agatston score specifically associated with small-vessel occlusive stroke.

Conclusions: IAC is a strong risk factor for recurrent stroke and post-stroke mortality. Among stroke subtypes, IAC relates to higher risk of stroke recurrence among patients with small-vessel disease, which indicates chronic calcification detected in large cerebral arteries may have potential effects on the cerebrovascular beds extending to small vessels.

Small dense low-density lipoprotein cholesterol is strongly associated with NIHSS score and intracranial arterial calcification in acute ischemic stroke subjects

Intracranial artery calcification (IAC) is an important risk factor for cerebral infarction and a key biomarker for intracranial artery stenosis. Small dense low-density lipoprotein cholesterol (sd-LDL-c) was independently associated with increased cardiovascular events and coronary calcification. Our study assessed whether sd-LDL-c is an independent factor for IAC in acute ischemic stroke (AIS) patients. This cross-sectional study involved a total of 754 patients with AIS (mean age: 65 ± 13.2 years). All the patients had received brain computed tomography angiography (CTA) examination to evaluate IAC. Serum sd-LDL-c levels and other biochemical parameters were analyzed. Admission NIHSS score and mRS score at discharge were collected. After 60-days 85 patients died during hospitalization and follow-up. Partial correlation analysis showed that serum sd-LDL-c levels were associated with admission NIHSS score and IAC score after adjusted age and gender. Logistic regression analysis showed that serum sd-LDL-c levels independently predicted NIHSS scores (β = 1.537, 95%CI: 0.134-2.878, p = 0.042) and IAC scores (β = 1.355, 95%CI: 0.319-2.446, p = 0.015). The average level of sd-LDL-c in patients who died was also significantly increased compared to survival patients (1.04 ± 0.59 vs 0.88 ± 0.44 mmol/L, p = 0.017). However, multivariate logistic regression analysis showed serum sd-LDL-c levels could not predict all-cause mortality and prognosis in AIS patients. Our study found that sd-LDL-c as a strong atherogenic lipid particle can independently predict admission NIHSS scores and the severity of cerebral artery calcification in AIS patients. However, its prognostic value in AIS patients still needs further study in the future.

Plaque features and vascular geometry in basilar artery atherosclerosis

Hemodynamic changes occurring at the segments of arterial bifurcations, up and down stream of stenotic vessels appear to play a critical role in the development of atherosclerosis. Therefore, we hypothesized that basilar artery (BA) geometry may be related to the distribution of atherosclerotic plaque.In this retrospective cross-sectional study, all patients hospitalized with ischemic stroke and intracranial atherosclerotic disease were sifted from March 2017 to October 2017. Sixty-seven patients with intracranial atherosclerotic disease (39 with and 28 without BA atherosclerosis) were analyzed. Magnetic resonance imaging, magnetic resonance angiography, and high-resolution black-blood MRI were performed within 7 days after symptoms onset. BA tortuosity, plaque location, and plaque enhancement were assessed. Plaque burden and vascular remodeling were measured.Of the 39 patients with BA atherosclerosis, plaques preferred to be formed at the inner arc than the outer arc (27/39, 69% vs 12/39, 31%) in the tortuous BA. In addition, patients with BA plaque had a greater vascular tortuosity compared with those without plaque (113.1 ± 10.2 vs 107 ± 4.6; P = .034). Finally, patients with apparent BA plaque had greater plaque enhancement (14/21, 67% vs 5/18, 28%; P = .017) and plaque burden (0.76 ± 0.15 vs 0.70 ± 0.09; P = .036) compared with those with minimal plaque.Plaque may be more likely to form at the inner arc of tortuous BA with atherosclerotic disease, and increased BA tortuosity is associated with its likelihood to form plaque.

Association between Serum Gamma-glutamyl transferase and Intracranial Arterial Calcification in Acute Ischemic Stroke Subjects

Intracranial artery calcification (IAC) is an important risk factor for cerebral infarction and a key biomarker for intracranial artery stenosis. Gamma-glutamyl transferase (GGT) has been independently associated with increased cardiovascular events and coronary calcification. Our study assessed whether GGT is an independent factor for IAC in acute ischemic stroke (AIS) patients. This cross-sectional study involved a total of 754 patients with AIS (mean age: 65 ± 13.2 years). All the patients had received brain computed tomography angiography (CTA) examination to evaluate IAC. Further, serum GGT levels and other biochemical parameters were analyzed. The average GGT level in patients who died was also significantly increased (37.0 ± 26.8 vs 29.0 ± 21.5 U/L, p = 0.012). Partial correlation analysis showed that serum GGT levels were associated with NIHSS score at admission after adjustment for age and gender was considered (r = 0.150, p = 0.001). Logistic regression analysis showed that serum GGT levels independently predicted all-cause mortality (OR = 1.036, 95% CI: 1.014-1.060, p = 0.002), NIHSS scores (β = 0.051, 95% CI: 0.020-0.082, p = 0.001) and IAC scores (β = 0.006, 95% CI: 0.003-0.014, p = 0.005) in male patients. Each SD (standard deviation) increase of serum GGT levels was also associated with risk of all-cause mortality (OR = 2.272, 95% CI: 1.364-3.787, P = 0.002). GGT levels in patients with severe IAC were significantly elevated (37.6 ± 33.6 vs 28.6 ± 19.2, p < 0.001). However, serum GGT levels could not independently predict the severity of IAC in AIS patients. Our study identified that serum GGT levels were significantly elevated in patients who died, and the GGT levels had a certain association with the risk of death and IAC in male patients.

Carotid artery calcification score and its association with cognitive impairment

Purpose

To retrospectively investigate the possible association between carotid artery calcification score (CS) and cognitive impairment in carotid artery stenosis (CAS) patients.

Patients and methods

Carotid artery was measured in 102 patients with cervical carotid arteries using Color Doppler ultrasound, multi-detector row spiral CT angiography and MRI scanning. Correlation analysis between CSs obtained by MD CT and cognitive scores was performed, and the correlation between CSs and vascular stenosis degree and MRI-measured plaque histological (lipid-rich necrotic nucleus [LRNC], intraplaque hemorrhage and fibrous cap surface rupture) and morphological parameters (lumen area [LA], wall area [WA], total area of blood vessels [TVA], plaque burden [PB]) was analyzed. Follow-up review analysis was conducted on 38 postoperative patients.

Results

Significant negative correlation was discovered between CS value and cognitive scores in CAS patients (R=-0.359, P<0.001), which did not exist in postoperative patients (P=0.348); CS value also showed significant correlation with WA (R=0.521, P=0.042), TVA (R=0.215, P=0.017) and PB (R=0.237, P=0.003) and had a certain predictive value for the occurrence probability of carotid plaque LRNC (P=0.029, AUC =0.780) in preoperative patients.

Conclusion

Carotid artery CSs have significant correlation with cognitive scores, which could be used as risk factor for early screening of cognitive impairment in CAS patients. The possible mechanism may be related to the calcification impact on the plaque burden.

Intracranial Arterial Calcification in Black Africans with Acute Ischaemic Stroke

Background

Intracranial arterial calcification (IAC), a recognized marker of atherosclerosis on cranial computed tomography (CT), is an independent risk factor for ischaemic stroke. This study aimed to determine the prevalence, distribution, severity, and associations of IAC in adults with acute ischaemic stroke (AIS) at the University College Hospital, Ibadan, Nigeria.

Methods

Cranial CT images of 130 consecutive adults who presented with AIS were acquired on a 64-slice multi-detector Toshiba Aquilion scanner and evaluated for IAC in bone window on Vitrea® software using a semi-quantitative scoring method for extent, thickness, and length of calcifications in the large intracranial arteries. Associations of IAC with clinical and laboratory data were determined by statistical analysis at p < 0.05.

Results

There were 71 males (54.6%), and the mean age of all patients was 63.0 ± 13.2 years. Hypertension was the most common risk factor (83.1%). IAC was found in 121 patients (93.1%), predominantly in the carotid siphon (86.1%) followed by the intracranial vertebral arteries (9.3%), middle cerebral arteries (2.4%), basilar artery (1.2%), and the anterior cerebral arteries (1%). The burden of IAC ranged from mild (17.4%) to moderate (52.1%) to severe (30.6%). Age (p < 0.001), diastolic blood pressure (p = 0.037), and alcohol use (0.046) were significantly different among the patients with mild, moderate, and severe degrees of IAC. IAC was associated with age (p < 0.001), hypertension (p = 0.03), diabetes mellitus (p = 0.02), hyperlipidaemia (p = 0.04), and alcohol use (p < 0.001) but not with sex (p = 0.35).

Conclusions

The burden of IAC is very high among native African patients with AIS and preferentially involves proximal inflow arteries. Therefore, the role of large vessel atherosclerosis in ischaemic stroke in native Africans should be explored in future multinational, multimodality studies.

Intracranial Artery Calcification and Its Clinical Significance

Intracranial arterial calcification (IAC) is an easily identifiable entity on plain head computed tomography scans. Recent studies have found high prevalence rates for IAC worldwide, and this may be associated with ischemic stroke and cognitive decline. Aging, traditional cardiovascular risk factors, and chronic kidney disease have been found to be associated with IAC. The severity of IAC can be assessed using different visual grading scales or various quantitative methods (by measuring volume or intensity). An objective method for assessing IAC using consistent criteria is urgently required to facilitate comparisons between multiple studies involving diverse populations. There is accumulating evidence from clinical studies that IAC could be utilized as an indicator of intracranial atherosclerosis. However, the pathophysiology underlying the potential correlation between IAC and ischemic stroke-through direct arterial stenosis or plaque stability-remains to be determined. More well-designed clinical studies are needed to explore the predictive values of IAC in vascular events and the underlying pathophysiological mechanisms.

Middle Cerebral Artery Calcification: Association With Ischemic Stroke

Calcification of the middle cerebral artery (MCA) is uncommon in the healthy elderly. Whether calcification of the MCA is associated with cerebral ischemic stroke remains undetermined. We intended to investigate the association using Agatston calcium scoring of the MCA. This study retrospectively included 354 subjects with ischemic stroke in the MCA territory and 1518 control subjects who underwent computed tomography (CT) of the brain. We recorded major known risk factors for ischemic stroke, including age, gender, hypertension, diabetes mellitus, smoking, hyperlipidemia, and obesity, along with the MCA calcium burden, measured with the Agatston calcium scoring method. Univariate and modified logistic regression analyses were performed to examine the association between the MCA calcification and ischemic stroke. The univariate analyses showed significant associations of ischemic stroke with age, hypertension, diabetes mellitus, smoking, total MCA Agatston score, and the presence of calcification on both or either side of the MCA. Subjects with the presence of MCA calcification on both or either side of the MCA were 8.46 times (95% confidence interval, 4.93-14.53; P < 0.001) more likely to have a cerebral infarct than subjects without MCA calcification after adjustment for the major known risk factors, including age, hypertension, diabetes mellitus, and smoking. However, a higher degree of MCA calcification reflected by the Agatston score was not associated with higher risk of MCA ischemic stroke after adjustment for the confounding factors and presence of MCA calcification. These results suggest that MCA calcification is associated with ischemic stroke in the MCA territory. Further prospective studies are required to verify the clinical implications of the MCA calcification.

High Agatston Calcium Score of Intracranial Carotid Artery: A Significant Risk Factor for Cognitive Impairment

The effect of intracranial internal carotid artery (ICA) calcification on cognitive impairment is uncertain. Our objective was to investigate whether intracranial ICA calcification is a significant cognitive predictor for cognitive impairment. Global cognition and degrees of intracranial ICA calcification of 579 subjects were assessed with Mini-Mental State Examination (MMSE) and Agatston calcium scoring method, respectively. Other risk factors for cognitive impairment, including age, education level, hypertension, diabetes mellitus, smoking, hyperlipidemia, and body mass index, were documented and analyzed for their associations with cognitive function. In univariate analyses, older age, lower education level, hypertension, diabetes mellitus, and higher intracranial ICA Agatston scores were significantly associated with cognitive impairment. In ordinal logistic regression, only age and total intracranial ICA Agatston score were significant risk factors for cognitive impairment. After adjustment for the other documented risk factors, subjects were 7% (95% CI: 5-10; P < 0.001) and 6% (95% CI: 0-13; P = 0.04) more likely to have lower cognitive category with every year increment of age and every 100-point increment of the total intracranial ICA Agatston score respectively. These results suggest an important role of the intracranial ICA calcification on cognitive impairment.

The predictive value of arterial and valvular calcification for mortality and cardiovascular events

A review of the predictive ability of arterial and valvular calcification has shown an additive effect of calcification in more than 1 location in predicting mortality and coronary heart disease, with mitral annual calcification being a particularly strong predictor. In individual arteries and valves there is a clear association between calcification presence, extent and progression and future cardiovascular events and mortality in asymptomatic, symptomatic and high risk patients, although adjustment for calcification in other arterial beds generally renders associations non-significant. Furthermore, in acute coronary syndrome, culprit plaque is normally not calcified. This would tend to reduce the validity of calcification as a predictor and suggest that the association with cardiovascular events and mortality may not be causal. The association with stroke is less clear; carotid and intracranial artery calcification show little predictive ability, with symptomatic plaques tending to be uncalcified.

Cerebral artery calcification in patients with acute cerebrovascular diseases: determinants and long-term clinical outcome

BACKGROUND AND PURPOSE

Coronary artery calcium is an independent predictor of all-cause mortality. We sought to examine the determinants of intracranial cerebral artery calcification (CAC) and its association with long-term outcome in a large prospective cohort of stroke patients.

METHODS

Consecutive patients hospitalized because of acute stroke (ischaemic and intracerebral hemorrhage) or TIA throughout a large medical center were systematically assessed and followed up for 1 year. Intracranial CAC was assessed from baseline brain CT blinded to clinical data. Patients were categorized to no, mild, and severe CAC according to their total CAC score. Determinants of CAC were studied with logistic regression analysis. Risk of death, Barthel Index ≤ 60 or death and living in a nursing facility or death were assessed.

RESULTS

  Amongst 1049 patients (mean age: 70 ± 13 years, 59% males) CAC was present in 727 (69%) patients. The main determinants of CAC were increasing age (OR 1.4, 95% CI 1.3-1.6, per 5 years), diabetes (OR: 2.1, 1.4-3.0), smoking (1.4, 1.0-2.2), hypertension (1.4, 1.0-2.1), and prior coronary heart disease (1.9, 1.3-2.9). CAC was associated with mortality and poor outcome amongst patients with ischaemic stroke; however, after adjusting for age and stroke severity, no significant association was observed. In patients with intracerebral hemorrhage, outcomes were not related to CAC.

CONCLUSIONS

  Intracranial CAC is highly prevalent in patients with acute stroke and its main determinants are older age, diabetes, smoking, hypertension, and prior coronary heart disease. Associations between CAC and mortality or poor functional outcome in the first year after ischaemic stroke are mainly age- and stroke severity-driven.

Presence of intracranial artery calcification is associated with mortality and vascular events in patients with ischemic stroke after hospital discharge: a cohort study

BACKGROUND AND PURPOSE

Although intracranial artery calcification (IAC) has been reported to be a risk factor for ischemic stroke, the prognostic implications of IAC in stroke outcome are unknown. The purpose of this study was to determine the association between IAC and risk of vascular events and death in patients with stroke after hospital discharge.

METHODS

All patients with ischemic stroke over a 1-year period were included (n=302). IAC, assessed by multidetector CT, was defined as hyperdense foci (peak density>130 Hounsfield units) and assessed in the 7 major cerebral arteries. The IAC scores ranged from 0 (no calcification) to 7. Follow-up information on major clinical events (including fatal or nonfatal ischemic stroke, cardiac and peripheral artery events, and all-cause death) was obtained by means of a structured phone interview.

RESULTS

IAC was present in 260 patients (83%). With a mean follow-up of 773±223 days, 88 major clinical events occurred in 67 patients (22%): 45 new ischemic vascular events (ischemic stroke: n=22; cardiac event: n=15; peripheral artery event: n=8) and 43 deaths from any cause. Patients with the highest IAC scores had significantly higher rates of death and vascular events than those with the lowest IAC scores (log rank test, P=0.029). In the Cox proportional hazards regression model, the IAC score was significantly associated with major clinical events (hazard ratio, 1.34; 95% CI, 1.11-1.61; P=0.002).

CONCLUSIONS

In patients with ischemic stroke, IAC detection may constitute a simple marker of a high risk of future major clinical events.

Intracranial arterial calcification is highly prevalent in hemodialysis patients but does not associate with acute ischemic stroke

Intracranial arterial calcification (IAC) is associated with ischemic stroke in the general population but this relationship has not been examined in hemodialysis patients. We examined the factors associated with IAC and its relationship with acute ischemic stroke in this population. We retrospectively studied 490 head computed tomographic scans from 2225 hemodialysis patients presenting with neurological symptoms at our center (October 2005-May 2009). Intracranial arterial calcification was graded using a validated scoring system. Multivariate regression was used to examine the factors associated with the presence of IAC, its severity, and its ability to predict acute ischemic stroke. Weibull's survival models analyzed the relationship between IAC severity and survival. Ninety-five percent of patients with ischemic stroke had IAC vs. 83% in the nonstroke group (P=0.02). Intracranial arterial calcification severity increased with age (P<0.001), hemodialysis vintage (P<0.001), serum phosphate (P<0.05), and major comorbidities. In patients with multiple computed tomographic scans during the study period, increased IAC severity at baseline was predictive of acute ischemic stroke (P=0.05) on logistic regression analysis. High-grade and not low-grade IAC was associated with worse survival (P=0.008). Intracranial arterial calcification is highly prevalent in hemodialysis patients, especially in those with acute ischemic stroke. Its severity is prognostically significant and associated with risk factors for vascular calcification and may confer a greater risk of acute ischemic stroke. The mechanisms underlying the high incidence of ischemic stroke in this patient group require further comprehensive study.

Arterial stiffness and asymptomatic intracranial large arterial stenosis and calcification in hypertensive chinese

BACKGROUND

Intracranial large artery disease (ICLAD), such as stenosis and calcification, is common in Chinese patients with stroke. However, little is known about ICLAD and its association with large arterial stiffness in hypertensive patients.

METHODS

We recruited 270 (mean age 61.0 years, 45.6% male) untreated hypertensive patients without stroke from a community in Shanghai, China. ICLAD was detected by computerized tomographic angiography (CTA). Carotid-femoral pulse wave velocity (cf-PWV), office, and 24-h ambulatory pulse pressure (PP) as well as ambulatory arterial stiffness index (AASI) were determined as the measures of arterial stiffness.

RESULTS

Among all participants, 26 (9.6%) had concurrent intracranial arterial stenosis and calcification, 11 (4.1%) stenosis only, and 71 (26.3%) calcifications only. After adjustment for age, mean arterial pressure, and other covariables, there was significant difference in cf-PWV (13.1 vs. 13.7 vs. 15.0 m/s; P = 0.0015) and 24-h PP (46.7 vs. 48.8 vs. 55.7 mm Hg; P = 0.0007) between patients with normal vessels (n = 162), with stenosis or calcification (n = 82), and with both lesions (n = 26). Multiple ordinal logistic regression analyses showed that both cf-PWV and 24-h PP were independently associated with ICLAD. Odds ratios (95% confidence interval (CI)) of ICLAD after multivariable and mutually adjustment were 1.51 (1.09-2.10) and 1.46 (1.06-2.01) for 1-s.d. increase in cf-PWV and 24-h PP, respectively. No significant association (P ≥ 0.10) with AASI or office PP was observed in multivariable analysis.

CONCLUSION

Increased arterial stiffness was independently associated with ICLAD. cf-PWV and 24-h PP might be useful in identifying those more likely to have ICLAD among hypertensive patients.

[Bilateral intracerebral angioplasty in a patient with stroke caused by giant cell arteritis]

INTRODUCTION

Giant cell arteritis is the most frequent vasculitis and can cause stroke in about 4% of the patients. The mechanism is often hemodynamic in relation with an arterial stenosis or occlusion. Optimal treatment remains to be defined. Outcome is often poor.

CASE REPORT

We report the case of a 78-year-old patient, with giant cell arteritis who developed neurological deterioration after the onset of the corticotherapy. Brain MRI revealed bilateral stroke caused by multiple preocclusive internal carotid stenosis. The patient was treated successfully with angioplasty and stenting.

CONCLUSION

Endovascular treatment could constitute an interesting alternative for patients with giant cell arteritis associated with neurological deterioration after a first episode of stroke because of hemodynamic instability or at stroke recurrence. For these patients, the usual medical treatment appears to be insufficient.