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Hurford R, Wolters FJ, Li L, Lau KK, Küker W, Rothwell PM. Prognosis of Asymptomatic Intracranial Stenosis in Patients With Transient Ischemic Attack and Minor Stroke. JAMA Neurol 2020; 77:947-954. [PMID: 32453401 PMCID: PMC7251503 DOI: 10.1001/jamaneurol.2020.1326] [Citation(s) in RCA: 34] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2019] [Accepted: 03/06/2020] [Indexed: 12/31/2022]
Abstract
Importance Asymptomatic intracranial stenosis (ICS) is a frequent finding on imaging results, particularly in the assessment of acute stroke. Although the management of symptomatic ICS is informed by randomized trials, to our knowledge there are few data on the prevalence and prognosis of asymptomatic ICS in patients with stroke and transient ischemic attack (TIA). Objective To study the age-specific prevalence and prognosis of asymptomatic ICS in a population-based cohort of patients with TIA and minor stroke. Design, Setting, and Participants All patients (predominantly white) recruited to the Oxford Vascular Study (Oxfordshire, England) between March 1, 2011, and March 1, 2018, with TIA and minor ischemic stroke (National Institutes of Health Stroke Scale score, ≤3), irrespective of age, were included (n = 1579). We determined the age-specific prevalence of 50% or more asymptomatic ICS and the associated stroke risk by face-to-face follow-up to 2018 on standard medical treatment without stenting. Exposures Patients underwent magnetic resonance angiography of the intracranial and cervicocranial arteries, computed tomography angiography if magnetic resonance angiography was contraindicated, or carotid/transcranial Doppler ultrasonography if computed tomography angiography was contraindicated. Main Outcomes and Measures The primary outcomes were the prevalence and prognosis of asymptomatic ICS. Results Of 1368 eligible patients (mean [SD] age, 69.2 [13.9] years; 700 men [51.2%]) with intracranial vascular imaging, 426 ICS were identified in 260 patients (19.0%): 58 (4.2%) with only symptomatic ICS, 155 (11.3%) with only asymptomatic ICS, and 47 (3.4%) with both. The prevalence of any asymptomatic ICS increased from 4.8% for patients younger than 70 years to 34.6% for patients 90 years or older (P for trend < .001; odds ratio per decade, 1.96; 95% CI, 1.69-2.27) and was greater than that of 50% or more asymptomatic carotid bifurcation stenosis (202 [14.8%] vs 105 patients [7.2%]; relative risk, 2.04; 95% CI, 1.63-2.55, P < .001). However, the 155 patients with only asymptomatic ICS had no increase in risk of ischemic stroke compared with those with no ICS (unadjusted HR, 1.03, 95% CI, 0.49-2.17), with 8 first recurrent events (5.2%) during 506 patient-years of follow-up and 3 in the territory of the ICS (annualized risk, 0.59%; 95% CI, 0.12-1.73). Conclusions and Relevance The prevalence of asymptomatic ICS increases with age in white patients with TIA and minor stroke and is greater than that of asymptomatic carotid stenosis, but asymptomatic ICS does not increase the short- or medium-term risk of distal recurrent ischemic stroke for patients receiving standard medical treatment.
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Affiliation(s)
- Robert Hurford
- Wolfson Centre for the Prevention of Stroke and Dementia, Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, England
| | - Frank J. Wolters
- Wolfson Centre for the Prevention of Stroke and Dementia, Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, England
| | - Linxin Li
- Wolfson Centre for the Prevention of Stroke and Dementia, Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, England
| | - Kui Kai Lau
- Wolfson Centre for the Prevention of Stroke and Dementia, Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, England
| | - Wilhelm Küker
- Wolfson Centre for the Prevention of Stroke and Dementia, Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, England
| | - Peter M. Rothwell
- Wolfson Centre for the Prevention of Stroke and Dementia, Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, England
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Chang KC, Chuang IC, Huang YC, Wu CY, Lin WC, Kuo YL, Lee TH, Ryu SJ. Risk factors outperform intracranial large artery stenosis predicting unfavorable outcomes in patients with stroke. BMC Neurol 2019; 19:180. [PMID: 31370812 PMCID: PMC6670158 DOI: 10.1186/s12883-019-1408-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2017] [Accepted: 07/22/2019] [Indexed: 12/24/2022] Open
Abstract
Background This study examined how intracranial large artery stenosis (ILAS), symptomatic and asymptomatic ILAS, and risk factors affect unfavorable outcome events after medical treatment in routine clinical practice. Methods This was a 24-month prospective observational study of consecutively recruited stroke patients. All participants underwent magnetic resonance angiography, and their clinical characteristics were assessed. Outcome events were vascular outcome, recurrent stroke, and death. Cox regression analyses were performed to identify potential factors associated with an unfavorable outcome, which included demographic and clinical characteristics, the risk factors, and stenosis status. Results The analysis included 686 patients; among them, 371 were assessed as ILAS negative, 231 as symptomatic ILAS, and 84 as asymptomatic ILAS. Body mass index (p < .05), hypertension (p = .01), and old infarction (p = .047) were factors relating to vascular outcomes. Hypertension was the only factor for recurrent stroke (p = .035). Poor glomerular filtration rate (< 30 mL/min/1.73 m2) (p = .011) and baseline National Institutes of Health Stroke Scale scores (p < .001) were significant predictors of death. Conclusions This study extended previous results from clinical trials to a community-based cohort study by concurrently looking at the presence/absence of stenosis and a symptomatic/asymptomatic stenotic artery. Substantiated risk factors rather than the stenosis status were predominant determinants of adverse outcome. Although the degree of stenosis is often an indicator for treatment, we suggest risk factors, such as hypertension and renal dysfunction, should be monitored and intensively treated.
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Affiliation(s)
- K C Chang
- Division of Cerebrovascular Diseases, Department of Neurology, Chang Gung Memorial Hospital, Linkou, Taiwan.,Discharge Planning Service Center, Chang Gung Memorial Hospital, Kaohsiung, Taiwan.,College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - I C Chuang
- Department of Occupational Therapy and Graduate Institute of Behavioral Sciences, College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Y C Huang
- Division of Cerebrovascular Diseases, Department of Neurology, Chang Gung Memorial Hospital, Linkou, Taiwan.,Department of Measurement and Statistics, Education, National University of Tainan, Tainan, Taiwan
| | - C Y Wu
- Department of Occupational Therapy and Graduate Institute of Behavioral Sciences, College of Medicine, Chang Gung University, Taoyuan, Taiwan. .,Department of Physical Medicine and Rehabilitation, Healthy Aging Research Center at Chang Gung University, Chang Gung Memorial Hospital at Linkou, 259 Wen-hwa 1st Road, Taoyuan, Taiwan.
| | - W C Lin
- Department of Radiology, Chang Gung Memorial Hospital, Kaohsiung, Taiwan
| | - Y L Kuo
- Department of Radiology, Chang Gung Memorial Hospital, Kaohsiung, Taiwan
| | - T H Lee
- Division of Cerebrovascular Diseases, Department of Neurology, Chang Gung Memorial Hospital, Linkou, Taiwan.,College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - S J Ryu
- Division of Cerebrovascular Diseases, Department of Neurology, Chang Gung Memorial Hospital, Linkou, Taiwan.,College of Medicine, Chang Gung University, Taoyuan, Taiwan
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Intracranial atherosclerotic disease. Neurobiol Dis 2018; 124:118-132. [PMID: 30439443 DOI: 10.1016/j.nbd.2018.11.008] [Citation(s) in RCA: 51] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2018] [Revised: 10/25/2018] [Accepted: 11/09/2018] [Indexed: 12/16/2022] Open
Abstract
Intracranial atherosclerosis (ICAS) is a progressive pathological process that causes progressive stenosis and cerebral hypoperfusion and is a major cause of stroke occurrence and recurrence around the world. Multiple factors contribute to the development of ICAS. Angiography imaging techniques can improve the diagnosis of and the selection of appropriate treatment regimens for ICAS. Neither aggressive medication nor endovascular interventions can eradicate stroke recurrence in patients with ICAS. Non-pharmacological therapies such as remote ischemic conditioning and hypothermia are emerging. Comprehensive therapy with medication in combination with endovascular intervention and/or non-pharmacological treatment may be a potential strategy for ICAS treatment in the future. We summarized the epidemiology, pathophysiological mechanisms, risk factors, biomarkers, imaging and management of ICAS.
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Tábuas-Pereira M, Sargento-Freitas J, Silva F, Parra J, Mendes P, Seara V, Mesquita M, Baptista M, Cordeiro G, Cunha L. Intracranial Internal Carotid Artery Wall Calcification in Ischemic Strokes Treated with Thrombolysis. Eur Neurol 2017; 79:21-26. [DOI: 10.1159/000477901] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2017] [Accepted: 05/25/2017] [Indexed: 11/19/2022]
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Concomitant Asymptomatic Intracranial Atherosclerotic Stenosis Increase the 30-Day Risk of Stroke in Patients Undergoing Symptomatic Intracranial Atherosclerotic Stenosis Stenting. J Stroke Cerebrovasc Dis 2017; 27:479-485. [PMID: 29056405 DOI: 10.1016/j.jstrokecerebrovasdis.2017.09.032] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2017] [Revised: 09/12/2017] [Accepted: 09/20/2017] [Indexed: 11/20/2022] Open
Abstract
BACKGROUND In the Stenting and Aggressive Medical Management for Preventing Recurrent Stroke in Intracranial Stenosis (SAMMPRIS) trial, 19.1% of ischemic strokes occurred out of the territory of previously symptomatic stenosis during the mean follow-up period of 23.4 months. However, it is unknown how many ischemic strokes were due to a previously asymptomatic intracranial atherosclerotic stenosis (ICAS). The objective of this study was to investigate whether the concomitant asymptomatic ICAS influences the outcome of patients undergoing symptomatic ICAS stenting. METHODS We retrospectively reviewed 576 consecutive patients with nondisabling ischemic stroke (modified Rankin scale score of ≤3) who were treated with symptomatic ICAS (≥70% stenosis) stenting with or without concomitant asymptomatic ICAS. The baseline characteristics and the 30-day primary end points (stroke or death after stenting) were compared by bivariate and multivariable logistic analyses. RESULTS The 30-day rate of primary end points was 5.2%, which was higher in patients with concomitant asymptomatic ICAS (≥50% stenosis) than in those without asymptomatic ICAS (no stenosis or <50% stenosis) (8.9% versus 3.8%, P = .014). In patients with concomitant asymptomatic ICAS, 25% of ischemic strokes occurred out of the territory of the stented artery, whereas in patients without asymptomatic ICAS, no ischemic stroke occurred out of the territory of the stented artery. Multivariable analysis showed that concomitant asymptomatic ICAS was an independent risk factor for 30-day stroke (odds ratio = 2.37, 95% confidence interval, 1.14-5.63; P = .023). CONCLUSIONS Concomitant asymptomatic ICAS (≥50% stenosis) might increase the 30-day risk of stroke in patients undergoing symptomatic ICAS stenting.
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Ram R, Kaul S, Alladi S, Afshan JS, Prabha TS, Kohat A, Tandra S, Rani JY. Risk Factors, Vascular Lesion Distribution, Outcome and Recurrence of Strokes Due to Intracranial Atherosclerosis: One Year Data from Hyderabad Stroke Registry. Ann Indian Acad Neurol 2017; 20:387-392. [PMID: 29184342 PMCID: PMC5682743 DOI: 10.4103/aian.aian_227_17] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Background: Intracranial atherosclerotic stenosis (ICAS) is a common cause of ischemic stroke in Asian countries and probably in India. Aim: The aim of this study was to describe the risk factors, distribution of vascular lesions, recurrence and outcome of stroke due to ICAS. Methodology: A total of 100 consecutive patients of ischemic stroke due to ICAS were enrolled prospectively from January 1, 2015, to December 31, 2015, and followed for 1 year for treatment compliance and recurrence. The details about demographics, risk factors, and vascular lesions were noted. Results: There were 68 males and 32 females. Hypertension (HTN), diabetes, alcohol, smoking, hyperlipidemia, and hyperhomocysteinemia was present in 82%, 52%, 34%, 33%, 28%, and 23%, respectively. The number of arteries involved were middle cerebral artery, 53 (37.3%); posterior cerebral artery, 24 (16.9%); internal cerebral artery, 21 (14.8%); vertebral artery, 18 (12.7%); basilar artery, 6 (4.2%); and anterior cerebral artery, 6 (4.2%). Seventeen (17%) patients had a recurrent stroke during 1 year follow-up. The presence of uncontrolled HTN and diabetes mellitus after discharge were significantly associated with stroke recurrence (P < 0.05). The use of dual antiplatelet agents and statins was found to have a significant effect in the prevention of recurrent stroke (P < 0.05). Severe stroke at presentation and presence of hemiparesis were the predictors for unfavorable outcome at 3 months (P < 0.05). Conclusion: Risk factors, distribution of vascular lesions and high recurrence of stroke due to ICAS in this study is similar to that reported from other Asian countries. Aggressive medical management and risk factor control remains the best strategy for preventing recurrence.
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Affiliation(s)
- Raghu Ram
- Department of Neurology, Nizams Institute of Medical Sciences, Hyderabad, Telangana, India
| | - Subhash Kaul
- Department of Neurology, Nizams Institute of Medical Sciences, Hyderabad, Telangana, India
| | - Suvarna Alladi
- Department of Neurology, Nizams Institute of Medical Sciences, Hyderabad, Telangana, India
| | - Jabeen S Afshan
- Department of Neurology, Nizams Institute of Medical Sciences, Hyderabad, Telangana, India
| | - T Surya Prabha
- Department of Neurology, Nizams Institute of Medical Sciences, Hyderabad, Telangana, India
| | - Abhijeet Kohat
- Department of Neurology, Nizams Institute of Medical Sciences, Hyderabad, Telangana, India
| | - Swetha Tandra
- Department of Neurology, Nizams Institute of Medical Sciences, Hyderabad, Telangana, India
| | - Jyotsna Y Rani
- Department of Radiology, Nizams Institute of Medical Sciences, Hyderabad, Telangana, India
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Matsui R, Nakagawa T, Takayoshi H, Onoda K, Oguro H, Nagai A, Yamaguchi S. A Prospective Study of Asymptomatic Intracranial Atherosclerotic Stenosis in Neurologically Normal Volunteers in a Japanese Cohort. Front Neurol 2016; 7:39. [PMID: 27047445 PMCID: PMC4801853 DOI: 10.3389/fneur.2016.00039] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2016] [Accepted: 03/07/2016] [Indexed: 11/13/2022] Open
Abstract
Atherosclerotic stenosis of major intracranial arteries is a leading cause of ischemic stroke in Asia. However, the long-term prognosis of asymptomatic intracranial atherosclerotic stenosis (ICAS) in healthy volunteers has not been fully examined. Here, we conducted a longitudinal study to examine the prognosis of healthy volunteers with asymptomatic ICAS and to determine the risk factors for ICAS, including asymptomatic brain parenchymal lesions. We studied 2,807 healthy Japanese volunteers with no history of stroke (mean age, 62.0 years). They were followed for a mean interval of 64.5 months. The degree of ICAS and the presence of asymptomatic brain lesions were assessed by using magnetic resonance imaging. Asymptomatic ICAS was detected in 166 volunteers (5.9%) at the initial examination. Moderate and mild stenoses were observed in 1.5 and 4.4% of patients, respectively. Significant risk factors for ICAS were older age and a history of hypertension and/or dyslipidemia. During follow-up, ischemic stroke developed in 32 volunteers. Seven strokes occurred in the ICAS group, whose stroke incidence rate was higher than that in the non-ICAS group (0.78 vs. 0.18% per year). According to a Cox regression analysis, asymptomatic ICAS was an independent risk factor for future ischemic stroke after adjustment for age. Furthermore, after asymptomatic brain lesions were taken into account, ICAS was still a significant risk factor for stroke onset. In conclusion, even mild to moderate asymptomatic ICAS was a significant risk factor for future stroke, independent of asymptomatic brain lesions, in a healthy Japanese population. Mild to moderate ICAS might be a therapeutic target for stroke prevention.
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Affiliation(s)
- Ryukichi Matsui
- Department of Neurology, Faculty of Medicine, Shimane University, Izumo, Japan; Department of Neurology, Masuda Red Cross Hospital, Masuda, Japan
| | - Tomonori Nakagawa
- Department of Neurology, Faculty of Medicine, Shimane University , Izumo , Japan
| | - Hiroyuki Takayoshi
- Department of Neurology, Faculty of Medicine, Shimane University , Izumo , Japan
| | - Keiichi Onoda
- Department of Neurology, Faculty of Medicine, Shimane University , Izumo , Japan
| | - Hiroaki Oguro
- Department of Neurology, Faculty of Medicine, Shimane University , Izumo , Japan
| | - Atsushi Nagai
- Department of Laboratory Medicine, Faculty of Medicine, Shimane University , Izumo , Japan
| | - Shuhei Yamaguchi
- Department of Neurology, Faculty of Medicine, Shimane University , Izumo , Japan
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Oshakbayev K, Dukenbayeva B, Otarbayev N, Togizbayeva G, Tabynbayev N, Gazaliyeva M, Idrisov A, Oshakbayev P. Weight loss therapy for clinical management of patients with some atherosclerotic diseases: a randomized clinical trial. Nutr J 2015; 14:120. [PMID: 26608649 PMCID: PMC4660604 DOI: 10.1186/s12937-015-0108-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2015] [Accepted: 11/13/2015] [Indexed: 11/29/2022] Open
Abstract
Background The prevalence and burden of atherosclerotic (AS) diseases are increasing during the last twenty years. Some studies show a close relationship between overweight and AS, but influence on AS diseases of different weight loss methods are still studying. The purpose of the research was to study the effectiveness of a weight loss program in AS patients in randomized controlled trial, and to develop a conception of evolution of AS. Methods A randomized controlled prospective clinical trial including 97 people, from them 71 patients with various AS manifestations. Patients were divided in 2 subgroups for non-drug weight loss program, and conventional drug therapy. The weight loss program included calorie restriction with 100–150 kcal/day, fat-free vegetables, salt diet, and optimum physical activity. Statistical analysis was performed using SPSS for Windows version 17.0. Results The weight loss subgroup lost ranging between 7-20 % from an initial weight (P = 0.016). Weight loss was achieved due to fatty mass reduction only (P = 0.005). Hemoglobin levels (P < 0.001), bone mineral density (P < 0.001), percentages of water (P = 0.006) and muscle masses (P = 0.0038) were increased in weight loss subgroup. Ejection fraction (P < 0.0001), systolic output (P < 0.0001) were increased in patients with coronary artery disease. The weight loss program led to a decrease in symptomatic drugs doses up to total abolition. A conception of AS was developed. Conclusions The weight loss program treated the AS diseases; improved laboratory and instrumental parameters, decreased symptomatic drugs doses. AS development is a logical way of ontogenetic ageing of body fat. Trial international registration ClinicalTrials.gov NCT01700075. Trial national registration State registration is # 0109RK000079, code is O.0475 at the National Center for Scientific and Technical Information of the Republic of Kazakhstan.
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Affiliation(s)
- Kuat Oshakbayev
- Department of metabolic syndrome, National Medical Holding, Astana, Kazakhstan.
| | - Bibazhar Dukenbayeva
- Faculty of pathology and forensic medicine, Medical University Astana, Astana, Kazakhstan.
| | - Nurzhan Otarbayev
- Department of cardiology, National Medical Holding, Astana, Kazakhstan.
| | | | - Nariman Tabynbayev
- Department of science and education, National Medical Holding, Astana, Kazakhstan.
| | - Meruyert Gazaliyeva
- Faculty of internal medicine, Karaganda State Medical University, Karaganda, Kazakhstan.
| | - Alisher Idrisov
- Faculty of endocrinology, Medical University Astana, Astana, Kazakhstan.
| | - Pernekul Oshakbayev
- Department of science and innovations, Medical University Astana, Astana, Kazakhstan.
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