Association of lacunar infarcts with small artery and large artery disease: a comparative study

Association of modifiable risk factors with ischaemic stroke subtypes in Asian versus Caucasian populations: A systematic review and meta-analysis

BACKGROUND

Ischaemic stroke (IS) is associated with various modifiable risk factors but the association of these risk factors based on TOAST classification, which characterises IS into five subtypes: large artery atherosclerosis (LAA), small vessel occlusion (SVO), cardioembolic disease (CE), other determined aetiology (ODE) and undetermined aetiology (UDE), is unknown. We aimed to summarise the published evidence for the association of modifiable risk factors with IS subtypes based on TOAST classification, specifically focussing on the Asian versus Caucasian population.

METHOD

A comprehensive search for all the published articles was performed in electronic databases including PubMed, EMBASE, Cochrane Library, and Google Scholar from 01st January 1950 to 10th April 2022 based on the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Odds ratio (OR) with 95% confidence interval (CIs) along with random-effect models was used to calculate summary estimates.

RESULTS

In our meta-analysis, 32 studies with a total of 23,404 IS (14,364 in Asian vs. 9040 in Caucasian population), 7121 LAA (5219 in Asian vs. 1902 in Caucasian), 5532 SVO (3604 in Asian vs. 1928 in Caucasian), 3498 CE (1634 in Asian vs. 1864 in Caucasian), 1131 ODE (546 in Asian vs. 585 in Caucasian) and 4519 UDE (2076 in Asian vs. 2443 in Caucasian) were included. Our findings suggest a significant association between LAA and hypertension (OR = 1.07, 95% CI = 1.02-1.12), smoking (OR = 1.11, 95% CI = 1.04-1.17), dyslipidemia (OR = 1.13, 95% CI = 1.06-1.21), diabetes mellitus (OR = 1.18, 95% CI = 1.11-1.25) and atrial fibrillation (OR = 0.55, 95% CI = 0.40-0.75). Significantly strong association of hypertension, smoking, dyslipidemia, diabetes mellitus and atrial fibrillation was observed with SVO and CE stroke subtypes. Subgroup analysis based on ethnicity revealed a significant association for dyslipidemia, diabetes mellitus and atrial fibrillation in LAA for both Asians and Caucasians. Hypertension was significantly associated with SVO and ODE subtypes in both Asians and Caucasians; however, only Asian population showed significant association of hypertension in LAA and CE subtypes. The other risk factors did not show any statistical difference between the ethnic groups for the different stroke subtypes. The majority of the risk factors depicted positive association with LAA and SVO, negative with CE and neutral with ODE and UDE.

CONCLUSION

Our findings suggest strong association of smoking, dyslipidemia and diabetes mellitus with LAA and SVO subtypes in the Caucasian population. However, only diabetes mellitus showed significant association with both LAA and SVO subtypes in Asian population as well. Thus, a majority of the traditional modifiable risk factors had a positive association in LAA and SVO, while a negative protective association was observed in CE subtype, among both the Asian and the Caucasian subgroups.

Advances in the Pharmacological Intervention of Endothelial Progenitor Cells in the Treatment of Ischemic Stroke

BACKGROUND

Ischemic stroke, a common central nervous system disease that seriously threatens human life and health, is characterized by rapid progress and a high disability fatality rate. Ischemic tissue can produce a large amount of vascular endothelial growth factor (VEGF) and stromal cell-derived factor 1 (SDF-1) to promote the mobilization of endothelial progenitor cells (EPCs).

SUMMARY

As newly discovered stem cells, EPCs can promote angiogenesis in ischemic tissue, repair the damaged vascular endothelium, and maintain vascular homeostasis. Thus, EPCs have become a new research hotspot in this field. This review focuses on the mechanism of EPCs and the intervention of various novel drugs, including small molecules and biomolecules, which will promote the capture, proliferation, and differentiation of EPCs. Then, we explore the promotion of vascular health and the prospect of its application in the treatment of cerebral ischemic stroke (CIS).

KEY MESSAGE

It is clinically significant to study the potential of new drug therapy to target EPCs. More effective cytokines, signal pathways, and other drugs should be explored in the future and their specific mechanisms determined. Research should reveal more biological functions of EPCs and achieve their efficient amplification to improve therapy against CIS stroke.

Atherosclerosis in intracranial or extracranial vessels in diabetic patients and the association with stroke subtype

Background

Diabetes mellitus (DM) is associated with increased prevalence and severity of atherosclerosis. This study aimed to assess the prevalence and location of atherosclerosis in intracranial and extracranial vessels in diabetic patients and to investigate their association with ischemic stroke subtype.

Methods

Diabetes patients (n=128) and nondiabetic patients (n=195) were enrolled. Brain MRI, MR angiography, and digital subtraction angiography (DSA) imaging findings in the two groups were retrospectively compared. The characteristics of atherosclerosis (prevalence, location, severity) and collateral flow in diabetic and nondiabetic patients and their association with stroke subtype were analyzed.

Results

Atherosclerosis in extracranial vessels was more common in diabetes patients than in nondiabetic patients (43.8% vs. 23.1%; P<0.001). Symptomatic stenoses were commonly in the proximal internal carotid artery (ICA) and proximal vertebral artery (pVA). Diabetes patients were more likely to have lacunar infarction (49.2% vs. 32.3%; P=0.002) and less likely to have large artery infarct (36.7% vs. 48.2%; P=0.042). DM (OR, 2.03; 95% CI, 1.96-4.30; P=0.006) and age >65 years (OR, 2.55; 95% CI, 1.24-5.22; P=0.011) were independent risk factors for lacunar infarct. Diabetes patients with symptomatic extracranial stenosis or occlusion, combined with good collateral circulation, had significantly higher risk of lacunar infarction than nondiabetic patients (47.8% vs. 30.5%; P=0.045).

Conclusions

DM aggravates the severity of extracranial atherosclerosis. Lacunar stroke is relatively common in diabetic patients and could even be due to large artery disease (LAD).

Periodontitis as a risk indicator and predictor of poor outcome for lacunar infarct

AIM

To investigate the association between periodontitis (PD) and lacunar infarct (LI) as well as to analyse whether PD could be a predictor of poor functional prognosis in patients with LI.

MATERIAL AND METHODS

Full-mouth periodontal examination was done in 120 cases (patients with LI) and 157 healthy controls. Demographic, clinical, medical and neurological information were collected from all of them. In addition, a measure of periodontal inflammation and disease activity, namely the periodontal inflamed surface area (PISA), was also calculated for each patient. Poor functional outcome was considered as a modified Rankin Scale >2 at 3 months.

RESULTS

PD was independently associated with the presence of LI (OR = 3.3, p < 0.001). Poor outcome was observed in 31 patients with LI (25.8%), of which 90.3% had PD. A PISA value ≥727 mm² was an independent predictor of poor prognosis, after adjusting for clinical confounders (OR = 6.5, p = 0.001).

CONCLUSIONS

PD and LI were associated. Active moderate to severe PD predicted poor prognosis in patients with LI. Further evidence is warranted to confirm our results and investigate potential mechanisms behind this association.

[A role of carotid endarterectomy in prevention of cerebral ischemic damage]

Authors present a literature review on the prevalence, clinical presentations, diagnosis and outcome of surgical treatment of atherosclerotic stenosis of the internal carotid artery.

Association of matrix metalloproteinases with MRI indices of brain ischemia and aging

Magnetic resonance imaging (MRI) findings of large white matter hyperintensities (LWMH), decreased brain volume and silent cerebral infarcts (SCI) are subclinical indices of brain ischemia and aging. Although the pathophysiology of these findings remains uncertain, extracellular matrix (ECM) remodeling, a process regulated by matrix metalloproteinases (MMPs) and their inhibitors (TIMPs), may be implicated. We evaluated the cross-sectional relations of circulating MMP-9 and TIMP-1 to these MRI indices in 583 stroke and dementia-free, Framingham Offspring participants (mean age 57 years, 58% women). Using multivariable regression MMP-9 (detectable versus non-detectable) and TIMP-1 (modeled as sex-specific quartiles) were related to LWMH (>1S.D. above age-specific mean; yes/no), SCI (yes/no) and total brain volume (ratio of parenchymal to intracranial volume, TCBVr). Mean TCBVr was 0.78 (S.D. 0.03), 13% of subjects had LWMH and 12% had SCI. Detectable MMP-9 was associated with higher prevalence of LWMH (OR 2.09, 95%confidence interval (CI) 1.00-4.37), but not with TCBVr. TIMP-1 was associated with a high prevalence of LWMH (OR for Q4 versus Q1-3: 1.83, 95%CI 1.06-3.18) and with lower mean TCBVr (Q4 associated with 0.17 S.D. units lower value relative to Q1-3; p=0.04). Neither biomarker was associated with SCI. Our findings are preliminary but if confirmed in further studies, suggest a pathophysiological role for the MMP/TIMP pathway in processes of brain ischemia and aging.

High blood pressure and inflammation are associated with poor prognosis in lacunar infarctions

Lacunar infarction has long been considered to be associated with good prognosis, however a significant percentage of these patients remain functionally dependent. In this study we sought to investigate the factors associated with poor outcome in patients with lacunar infarction.

SUBJECTS AND METHODS

We have performed a secondary study in 113 patients with lacunar infarctions admitted within the first 24 h of symptom onset (mean age 70 years, 57.5% men). Blood pressure, body temperature, serum glucose levels, neurotransmitters and pro-inflammatory markers were measured at admission and during the first 72 h. Stroke severity was assessed by the Canadian Stroke Scale (CSS). Neuroimaging evaluation was performed at admission and between days 4 and 7. Poor functional outcome was considered as a Barthel index <85 at 3 months.

RESULTS

36 patients (31.9%) had poor outcome. Older age (p = 0.009), history of hypertension (p = 0.005), higher body temperature (p < 0.0001), systolic blood pressure (SBP) (p = 0.010), serum glucose (p = 0.002) and interleukin-6 (IL-6) (p < 0.0001) levels, as well as lower CSS score at admission (p < 0.0001) were all predictive factors of poor outcome in bivariate analyses. SBP at admission (OR 2.07, CI 95% 1.04-3.28, p = 0.015) was the only clinical predictor on multivariate analysis. When the logistic model was further adjusted for biomarkers of inflammation and excitotoxicity, IL-6 levels (OR 1.09, CI 95% 1.01-1.26, p = 0.003), but not SBP, was independently associated with poor outcome. This association persisted even after adjusting for potential predictors recorded during the first 72 h of hospitalization.

CONCLUSION

High SBP and IL-6 levels on admission may predict poor outcome in patients with lacunar infarction.

Flow-mediated dilatation and intima-media thickness in patients with lacunar infarctions

OBJECTIVES

To evaluate systemic endothelial function and atherosclerotic changes in patients with lacunar infarctions (LI) we examined flow-mediated dilatation (FMD) and intima-media thickness (IMT) and compared them to patients with similar risk factors (SR) and healthy controls.

METHODS

FMD and IMT were investigated in patients with LI (20 patients, aged 60.9 +/- 7.3 years), 21 age- and gender-matched patients with SR and 21 healthy controls.

RESULTS

FMD was more impaired in patients with LI (0.4% +/- 5.0%) compared to patients with SR (3.8% +/- 4.8%) and healthy controls (7.9% +/- 6.0%) (P < or = 0.01), whereas IMT was similarly thickened in both groups of patients.

CONCLUSIONS

We found that patients with LI have a diminished FMD, but a similar IMT, compared to patients with SR. Our results reveal that for a given level of atherosclerosis patients with LI have additional endothelial impairment.