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Carlson AP, Mayer AR, Cole C, van der Horn HJ, Marquez J, Stevenson TC, Shuttleworth CW. Cerebral autoregulation, spreading depolarization, and implications for targeted therapy in brain injury and ischemia. Rev Neurosci 2024; 35:651-678. [PMID: 38581271 PMCID: PMC11297425 DOI: 10.1515/revneuro-2024-0028] [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: 02/22/2024] [Accepted: 03/25/2024] [Indexed: 04/08/2024]
Abstract
Cerebral autoregulation is an intrinsic myogenic response of cerebral vasculature that allows for preservation of stable cerebral blood flow levels in response to changing systemic blood pressure. It is effective across a broad range of blood pressure levels through precapillary vasoconstriction and dilation. Autoregulation is difficult to directly measure and methods to indirectly ascertain cerebral autoregulation status inherently require certain assumptions. Patients with impaired cerebral autoregulation may be at risk of brain ischemia. One of the central mechanisms of ischemia in patients with metabolically compromised states is likely the triggering of spreading depolarization (SD) events and ultimately, terminal (or anoxic) depolarization. Cerebral autoregulation and SD are therefore linked when considering the risk of ischemia. In this scoping review, we will discuss the range of methods to measure cerebral autoregulation, their theoretical strengths and weaknesses, and the available clinical evidence to support their utility. We will then discuss the emerging link between impaired cerebral autoregulation and the occurrence of SD events. Such an approach offers the opportunity to better understand an individual patient's physiology and provide targeted treatments.
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Affiliation(s)
- Andrew P. Carlson
- Department of Neurosurgery, University of New Mexico School of Medicine, MSC10 5615, 1 UNM, Albuquerque, NM, 87131, USA
- Department of Neurosciences, University of New Mexico School of Medicine, 915 Camino de Salud NE, Albuquerque, NM, 87106, USA
| | - Andrew R. Mayer
- Mind Research Network, 1101 Yale, Blvd, NE, Albuquerque, NM, 87106, USA
| | - Chad Cole
- Department of Neurosurgery, University of New Mexico School of Medicine, MSC10 5615, 1 UNM, Albuquerque, NM, 87131, USA
| | | | - Joshua Marquez
- University of New Mexico School of Medicine, 915 Camino de Salud NE, Albuquerque, NM, 87106, USA
| | - Taylor C. Stevenson
- Department of Neurosurgery, University of New Mexico School of Medicine, MSC10 5615, 1 UNM, Albuquerque, NM, 87131, USA
| | - C. William Shuttleworth
- Department of Neurosciences, University of New Mexico School of Medicine, 915 Camino de Salud NE, Albuquerque, NM, 87106, USA
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2
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Sabayan B, Akhavan Sigari A, Modir R, Meyer BC, Hemmen T, Meyer D, Bavarsad Shahripour R. Statin treatment intensity and cerebral vasomotor reactivity response in patients with ischemic stroke. J Neuroimaging 2024; 34:445-450. [PMID: 38590021 DOI: 10.1111/jon.13200] [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: 02/13/2024] [Revised: 03/08/2024] [Accepted: 03/25/2024] [Indexed: 04/10/2024] Open
Abstract
BACKGROUND AND PURPOSE Cerebral vasomotor reactivity (VMR) is vital for regulating brain blood flow and maintaining neurological function. Impaired cerebral VMR is linked to a higher risk of stroke and poor post-stroke outcomes. This study explores the relationship between statin treatment intensity and VMR in patients with ischemic stroke. METHODS Seventy-four consecutive patients (mean age 69.3 years, 59.4% male) with recent ischemic stroke were included. VMR levels were assessed 4 weeks after the index stroke using transcranial Doppler, measuring the breath-holding index (BHI) as an indicator of the percentage increase in middle cerebral artery blood flow (higher BHI signifies higher VMR). Multistep multivariable regression models, adjusted for demographic and cerebrovascular risk factors, were employed to examine the association between statin intensity treatment and BHI levels. RESULTS Forty-one patients (55%) received high-intensity statins. Patients receiving high-intensity statins exhibited a mean BHI of 0.85, whereas those on low-intensity statins had a mean BHI of 0.67 (mean difference 0.18, 95% confidence interval: 0.13-0.22, p-value<.001). This significant difference persisted in the fully adjusted model (adjusted mean values: 0.84 vs. 0.68, p-value: .008). No significant differences were observed in BHI values within patient groups on high-intensity or low-intensity statin therapy (all p-values>.05). Furthermore, no significant association was found between baseline low-density lipoprotein (LDL) levels and BHI. CONCLUSIONS High-intensity statin treatment post-ischemic stroke is linked to elevated VMR independent of demographic and clinical characteristics, including baseline LDL level. Further research is needed to explore statin therapy's impact on preserving brain vascular function beyond lipid-lowering effects.
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Affiliation(s)
- Behnam Sabayan
- Department of Neurology, Hennepin Healthcare Research Institute, Minneapolis, Minnesota, USA
- Division of Epidemiology and Community Health, School of Public Health, University of Minnesota, Minneapolis, Minnesota, USA
| | | | - Royya Modir
- UCSD Comprehensive Stroke Center, Department of Neurosciences, University of California, San Diego, California, USA
| | - Brett C Meyer
- UCSD Comprehensive Stroke Center, Department of Neurosciences, University of California, San Diego, California, USA
| | - Thomas Hemmen
- UCSD Comprehensive Stroke Center, Department of Neurosciences, University of California, San Diego, California, USA
| | - Dawn Meyer
- UCSD Comprehensive Stroke Center, Department of Neurosciences, University of California, San Diego, California, USA
| | - Reza Bavarsad Shahripour
- UCSD Comprehensive Stroke Center, Department of Neurosciences, University of California, San Diego, California, USA
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3
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Lee KP, Huang HC, Tsai JY, Hsu LC. Statin treatment in stroke patient with low-density lipoprotein cholesterol levels below 70 mg/dL. J Stroke Cerebrovasc Dis 2024; 33:107645. [PMID: 38395098 DOI: 10.1016/j.jstrokecerebrovasdis.2024.107645] [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: 12/16/2023] [Revised: 01/08/2024] [Accepted: 02/20/2024] [Indexed: 02/25/2024] Open
Abstract
BACKGROUND AND PURPOSE The effectiveness of hyperlipidemia treatment in strokes secondary prevention has been established. However, whether pretreatment with statins could confer protective effects when a patient's baseline low-density lipoprotein cholesterol (LDL-C) level is <70 mg/dL remains uncertain. Additionally, the ability of statin treatment to reduce poststroke complications, mortality, and recurrence in this patient group is unclear. METHODS AND RESULTS In this retrospective observational study, we enrolled patients who had experienced an ischemic stroke with LDL-C levels <70 mg/dL. We analyzed the association of statin use with baseline characteristics, stroke severity, in-hospital complications, mortality rates, stroke recurrence rate, and mortality rate. Patients who used and patients who did not use statins were similar in terms of age and sex. Patients using statins had higher rates of diabetes mellitus, hypertension, prior stroke, and coronary artery disease but a lower incidence of atrial fibrillation. Stroke severity was less pronounced in those using statins. We also evaluated the relationship between in-hospital statin use and complications. We noted that in-hospital statin use was associated with lower rates of infection, hemorrhagic transformation, gastrointestinal hemorrhage, and mortality, as well as higher rates of positive functional outcomes. The 1-year recurrence rate was similar in both groups. CONCLUSIONS Statin use is associated with milder strokes and improved poststroke outcomes, even in patients with well-controlled LDL levels. Neurologists may consider prescribing statins for patients with ischemic stroke who do not overt hyperlipidemia. Further research into potential underlying mechanisms is warranted.
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Affiliation(s)
- Kang-Po Lee
- Department of Neurology, Tainan Sin Lau Hospital, Tainan, Taiwan; Institute of Clinical Medicine, College of Medicine, National Cheng Kung University, Tainan, Taiwan
| | - Hui-Chi Huang
- Department of Nursing, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Jui-Yao Tsai
- Department of Nursing, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Li-Chi Hsu
- Department of Neurology, Taipei Veterans General Hospital, Taipei, Taiwan; School of Medicine, College of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan.
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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.
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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
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Skouras P, Kalamatianos T, Markouli M, Karagiannis A, Stavrinou LC. The Landscape of Randomized Clinical Trial Meta-analyses on Statins for Aneurysmal Subarachnoid Hemorrhage: A Scoping Review. CNS & NEUROLOGICAL DISORDERS DRUG TARGETS 2024; 23:1320-1327. [PMID: 37855296 DOI: 10.2174/0118715273270503230928100141] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/04/2023] [Revised: 08/12/2023] [Accepted: 08/12/2023] [Indexed: 10/20/2023]
Abstract
INTRODUCTION Aneurysmal subarachnoid hemorrhage (aSAH) is a type of non-traumatic SAH that can have detrimental effects on the central nervous system, resulting in severe disability or death. METHODS Early nimodipine is currently the only strongly recommended pharmacological treatment that has shown efficacy in improving neurological/functional outcomes in aSAH patients. Whether statin treatment is of benefit to aSAH patients is an issue that has generated considerable interest and debate. In the present scoping review, we mapped and analyzed the available literature on metaanalyses of randomized clinical trials (RCTs) examining the effect of statins on aSAH. Seventeen meta-analyses of RCTs, published between 2008 and 2023, were identified. RESULTS Treatments in included meta-analyses were based on various regimens of simvastatin, pravastatin, pitavastatin or atorvastatin for up to 21 days. Eleven of the included reports indicated some beneficial effect of statin treatment, reducing rates of at least one of the following: cerebral vasospasm, delayed cerebral ischemia/delayed ischemic neurologic deficit, mortality or functional/ neurological outcome. In contrast, six meta-analyses, showed no such effects. CONCLUSION The limitations reported by several meta-analyses, included low patient numbers or disproportionate representation of patients from certain RCTs, differences in drug treatment, patient diagnostic criteria and outcome evaluation between RCTs, as well as poor data quality or lack of RCTs data. Knowledge of the reported limitations may aid the design of future clinical trials and/or their meta-analyses.
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Affiliation(s)
- Panagiotis Skouras
- 1st Department of Neurosurgery, Evangelismos Hospital, National and Kapodistrian University of Athens, Greece
| | - Theodosis Kalamatianos
- 1st Department of Neurosurgery, Evangelismos Hospital, National and Kapodistrian University of Athens, Greece
| | - Mariam Markouli
- Department of Internal Medicine, Boston Medical Center, Boston University School of Medicine, Boston, MA 02118, USA
| | | | - Lampis C Stavrinou
- 2nd Department of Neurosurgery, Attikon Hospital, National and Kapodistrian University of Athens, Greece
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Llwyd O, Fan JL, Müller M. Effect of drug interventions on cerebral hemodynamics in ischemic stroke patients. J Cereb Blood Flow Metab 2022; 42:471-485. [PMID: 34738511 PMCID: PMC8985436 DOI: 10.1177/0271678x211058261] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
The ischemic penumbra is sensitive to alterations in cerebral perfusion. A myriad of drugs are used in acute ischemic stroke (AIS) management, yet their impact on cerebral hemodynamics is poorly understood. As part of the Cerebral Autoregulation Network led INFOMATAS project (Identifying New Targets for Management and Therapy in Acute Stroke), this paper reviews some of the most common drugs a patient with AIS will come across and their potential influence on cerebral hemodynamics with a particular focus being on cerebral autoregulation (CA). We first discuss how compounds that promote clot lysis and prevent clot formation could potentially impact cerebral hemodynamics, before focusing on how the different classes of antihypertensive drugs can influence cerebral hemodynamics. We discuss the different properties of each drug and their potential impact on cerebral perfusion and CA. With emerging interest in CA status of AIS patients, either during or soon after treatment when timely reperfusion and salvageable tissue is at its most critical, the properties of these pharmacological agents may be relevant for modelling cerebral perfusion accuracy and for setting individualised treatment strategies.
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Affiliation(s)
- Osian Llwyd
- Department of Cardiovascular Sciences, Cerebral Haemodynamics in Ageing and Stroke Medicine Research Group, University of Leicester, Leicester, UK
| | - Jui-Lin Fan
- Manaaki Manawa - The Centre for Heart Research, Department of Physiology, Faculty of Medical & Health Sciences, University of Auckland, Auckland, New Zealand
| | - Martin Müller
- Neurozentrum, Klinik für Neurologie und Neurorehabilitation, Luzerner Kantonsspital, Spitalstrasse, Luzern, Switzerland
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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: 11] [Impact Index Per Article: 3.7] [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.
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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.)
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Bohara S, Gaonkar VB, Garg K, Rajpal PMS, Singh PK, Singh M, Suri A, Chandra PS, Kale SS. Effect of statins on functional outcome and mortality following aneurysmal subarachnoid hemorrhage - Results of a meta-analysis, metaregression and trial sequential analysis. Clin Neurol Neurosurg 2021; 207:106787. [PMID: 34225002 DOI: 10.1016/j.clineuro.2021.106787] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2021] [Revised: 06/22/2021] [Accepted: 06/23/2021] [Indexed: 11/17/2022]
Abstract
OBJECTIVE Cerebral vasospasm (CVS) and delayed ischemic neurological deficits (DIND) are a common cause of morbidity following aneurysmal subarachnoid hemorrhage (SAH). Statins have been shown to decrease CVS. The objective of this article was to ascertain the effect of statins on functional outcome and mortality following aneurysmal SAH by performing meta-analysis. METHODS A comprehensive search of different databases was performed to retrieve randomized controlled trials. Meta-analysis with subgroup analysis and metaregression was done. Trial sequential analysis (TSA) was performed to determine if the cumulative sample size was appropriately powered for the obtained pooled effect values and to avoid random error. RESULTS Twelve articles were selected for meta-analysis. Pooled OR for the change in favorable outcome, mortality, CVS, DIND and elevated transaminases was 1.07 (p = 0.55), 0.78 (p = 0.17), 0.58 (p = 0.0004), 0.54 (p = 0.0293) and 0.68 (p = 0.1774) respectively. Further, subgroup analysis and metaregression showed that the use of different statin or dose did not result in significant variation in results in the parameters studied. TSA showed that more trials and patients are required to reach to a definitive conclusion regarding any effect on statins on functional outcome and mortality as the current studies neither reached the level of confidence nor crossed the futility boundary. CONCLUSION Use of statins in patients with aneurysmal SAH resulted in marginal but non-significant favorable impact on functional outcome and mortality. TSA showed that more studies are required to get conclusive evidence in this regard.
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Affiliation(s)
- Sandeep Bohara
- Department of Neurosurgery, All India Institute of medical Sciences, New Delhi, India
| | | | - Kanwaljeet Garg
- Department of Neurosurgery, All India Institute of medical Sciences, New Delhi, India.
| | | | - Pankaj Kumar Singh
- Department of Neurosurgery, All India Institute of medical Sciences, New Delhi, India
| | - Manmohan Singh
- Department of Neurosurgery, All India Institute of medical Sciences, New Delhi, India
| | - Ashish Suri
- Department of Neurosurgery, All India Institute of medical Sciences, New Delhi, India
| | - P S Chandra
- Department of Neurosurgery, All India Institute of medical Sciences, New Delhi, India
| | - S S Kale
- Department of Neurosurgery, All India Institute of medical Sciences, New Delhi, India
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Nam KW, Kwon HM, Lee YS. Distinct association between cerebral arterial pulsatility and subtypes of cerebral small vessel disease. PLoS One 2020; 15:e0236049. [PMID: 32673353 PMCID: PMC7365409 DOI: 10.1371/journal.pone.0236049] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2020] [Accepted: 06/27/2020] [Indexed: 01/08/2023] Open
Abstract
Background Increased arterial resistance is a potential pathological mechanism of cerebral small vessel disease (cSVD). Aim In this study, we aimed to investigate the association between pulsatility index (PI) representing cerebral arterial resistance and subtypes of cSVD in patients with lacunar stroke. Methods We included consecutive lacunar stroke patients between 2010 and 2013. White matter hyperintensity (WMH) volume was rated using semi-automated quantitative methods. Additionally, the presence of old lacunar infarct (OLI), cerebral microbleed (CMB), or enlarged perivascular space (EPVS) was also evaluated. The relationship between PI, measured in each middle cerebral artery, and the subtype/burden of cSVD was analyzed in the relevant hemisphere. Results A total of 206 lacunar patients were included and 412 hemispheres were analyzed (mean age: 64 years, male: 68.4%). In multivariable analysis, PI was positively associated with the WMH volume [beta = 1.372, 95% confidence interval (CI) = 0.624 to 2.120, P < 0.001] after adjusting for confounders. PI was also related to the presence of OLI (adjusted odds ratio = 11.37, 95% CI = 2.55–48.56, P = 0.001); however, this relationship was not significant in CMB or EPVS. Regarding the cSVD burden, PI increased according to the WMH tertiles (P for trend < 0.001), the burden of OLI (P for trend < 0.001), and EPVS tertiles (P for trend < 0.001), showing a quantitative relationship. Conclusions Ipsilateral PI is closely associated with cSVD in patients with lacunar stroke. Furthermore, this association is different between subtypes of cSVD, which is suggestive of underlying pathophysiological differences.
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Affiliation(s)
- Ki-Woong Nam
- Department of Neurology, Seoul Metropolitan Government-Seoul National University Boramae Medical Center, Seoul, Korea
- Seoul National University College of Medicine, Seoul, Korea
| | - Hyung-Min Kwon
- Department of Neurology, Seoul Metropolitan Government-Seoul National University Boramae Medical Center, Seoul, Korea
- Seoul National University College of Medicine, Seoul, Korea
| | - Yong-Seok Lee
- Department of Neurology, Seoul Metropolitan Government-Seoul National University Boramae Medical Center, Seoul, Korea
- Seoul National University College of Medicine, Seoul, Korea
- * E-mail:
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Castello-Branco RC, Cerqueira-Silva T, Andrade AL, Gonçalves BMM, Pereira CB, Felix IF, Santos LSB, Porto LM, Marques MEL, Catto MB, Oliveira MA, de Sousa PRSP, Muiños PJR, Maia RM, Schnitman S, Oliveira-Filho J. Association Between Risk of Obstructive Sleep Apnea and Cerebrovascular Reactivity in Stroke Patients. J Am Heart Assoc 2020; 9:e015313. [PMID: 32164495 PMCID: PMC7335520 DOI: 10.1161/jaha.119.015313] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Background Obstructive sleep apnea (OSA) is present in 60% to 70% of stroke patients. Cerebral vasoreactivity in patients with stroke and OSA has not been well studied and could identify a new pathophysiologic mechanism with potential therapeutic intervention. We aimed to determine whether risk categories for OSA are associated with cerebral vasoreactivity in stroke patients. Methods and Results In this cross-sectional study of a cohort of patients with stroke, we used clinical questionnaires (Sleep Obstructive Apnea Score Optimized for Stroke [SOS] and snoring, tiredness, observed, pressure, bmi, age, neck, gender [STOP-BANG] scores) to assess the risk of OSA and transcranial Doppler to assess cerebral vasoreactivity (breath-holding index and visual evoked flow velocity response). Of the 99 patients included, 77 (78%) had medium or high risk of OSA and 80 performed transcranial Doppler. Mean breath-holding index was 0.52±0.37, and median visual evoked flow velocity response was 10.8% (interquartile range: 8.8-14.5); 54 of 78 (69%) showed impaired anterior circulation vasoreactivity (breath-holding index <0.69) and 53 of 71 (75%) showed impaired posterior circulation vasoreactivity (visual evoked flow velocity response ≤14.0%). There was a significant negative correlation between the risk of OSA calculated by STOP-BANG and the breath-holding index (rS=-0.284, P=0.012). The following variables were associated with low anterior circulation vasoreactivity: dyslipidemia (odds ratio: 4.7; 95% CI, 1.5-14.2) and STOP-BANG score (odds ratio: 1.7 per 1-point increase; 95% CI, 1.1-1.5). Conclusions A high risk of OSA and impaired vasoreactivity exists in the population that has had stroke. Dyslipidemia and STOP-BANG sleep apnea risk categories were independently associated with impaired anterior circulation vasoreactivity.
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Affiliation(s)
| | - Thiago Cerqueira-Silva
- Stroke Clinic, Hospital Professor Edgard Santos Federal University of Bahia Salvador Brazil
| | - Alisson L Andrade
- Stroke Clinic, Hospital Professor Edgard Santos Federal University of Bahia Salvador Brazil
| | - Beatriz M M Gonçalves
- Stroke Clinic, Hospital Professor Edgard Santos Federal University of Bahia Salvador Brazil
| | - Camila B Pereira
- Stroke Clinic, Hospital Professor Edgard Santos Federal University of Bahia Salvador Brazil
| | - Iuri F Felix
- Stroke Clinic, Hospital Professor Edgard Santos Federal University of Bahia Salvador Brazil
| | - Leila S B Santos
- Stroke Clinic, Hospital Professor Edgard Santos Federal University of Bahia Salvador Brazil
| | - Louise M Porto
- Stroke Clinic, Hospital Professor Edgard Santos Federal University of Bahia Salvador Brazil
| | - Maria E L Marques
- Stroke Clinic, Hospital Professor Edgard Santos Federal University of Bahia Salvador Brazil
| | - Marilia B Catto
- Stroke Clinic, Hospital Professor Edgard Santos Federal University of Bahia Salvador Brazil
| | - Murilo A Oliveira
- Stroke Clinic, Hospital Professor Edgard Santos Federal University of Bahia Salvador Brazil
| | - Paulo R S P de Sousa
- Stroke Clinic, Hospital Professor Edgard Santos Federal University of Bahia Salvador Brazil
| | - Pedro J R Muiños
- Stroke Clinic, Hospital Professor Edgard Santos Federal University of Bahia Salvador Brazil
| | - Renata M Maia
- Stroke Clinic, Hospital Professor Edgard Santos Federal University of Bahia Salvador Brazil
| | - Saul Schnitman
- Stroke Clinic, Hospital Professor Edgard Santos Federal University of Bahia Salvador Brazil
| | - Jamary Oliveira-Filho
- Stroke Clinic, Hospital Professor Edgard Santos Federal University of Bahia Salvador Brazil
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Cui CC, Sun Y, Wang XY, Zhang Y, Xing Y. The effect of anti-dementia drugs on Alzheimer disease-induced cognitive impairment: A network meta-analysis. Medicine (Baltimore) 2019; 98:e16091. [PMID: 31277107 PMCID: PMC6635177 DOI: 10.1097/md.0000000000016091] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/12/2018] [Revised: 03/27/2019] [Accepted: 05/26/2019] [Indexed: 11/27/2022] Open
Abstract
BACKGROUND Cognitive impairment is a principal manifestation of Alzheimer disease (AD). To provide a clinical reference for the treatment of AD, a network meta-analysis (NMA) was performed to evaluate the effects of different anti-dementia drugs on the cognitive impairment exhibited by patients with AD. METHODS Relevant randomized controlled trials are found through the Pubmed database, Web of Science, Clinical Trials, Embase, Cohranne library, Chinese National Knowledge Infrastructure database, CBM databases, and Wanfang among others. A total of 33 articles were collected, with the earliest document collected having been published in February 2017. The included reports were screened for quality of papers by using strict inclusion and exclusion criteria. All analyses were based on previously published studies reporting de-identified data; thus, no ethical approval or patient consent were required. The Mini-Mental State Examination scores informed the classification of the 33 articles into a mild subgroup, which featured 11 articles, and 12 drugs (besides a placebo); a moderate subgroup, which featured 17 articles and 15 drugs (besides a placebo); and a severe subgroup, which featured 5 articles and 3 drugs (besides a placebo). RESULTS While donepezil, galanthamine, and huperzine demonstrated the highest efficacy in the mild cognitive dysfunction subgroup (mean difference = 5.2, 2.5, and 2.4, respectively). Donepezil, huperzine A, and rivastigmine achieved the most significant effects in the moderate cognitive dysfunction subgroup (MD = 3.8, 2.9, and 3.0 respectively). In the severe subgroup, donepezil was demonstrably superior to memantine. Donepezil was thus found to effectively address cognitive impairment in patients with AD regardless of the degrees of cognitive decline. CONCLUSIONS Evaluation of the clinically common anti-dementia drugs using NMA affirmed the utility of cholinesterase inhibitors, especially donepezil, in alleviating cognitive dysfunction of patients with AD. This study may therefore help to inform the clinical selection of pharmacotherapeutic interventions addressing cognitive dysfunction in patients with AD.
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Krel M, Miulli DE, Jung H, Wiginton JG, Brazdzionis J, Wacker MR, Hoshek S, Menoni R. Minimization of Intraparenchymal Hemorrhagic Stroke Size by Optimization of Serum Lipids. Cureus 2019; 11:e4406. [PMID: 31245196 PMCID: PMC6559677 DOI: 10.7759/cureus.4406] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
Introduction Intraparenchymal hemorrhages (IPHs) are the most common type of hemorrhagic stroke. One of the main associated risk factors is total cholesterol (TC) above 200. A severely decreased level of TC potentially interferes with the stabilization of the cell membrane and can potentially lead to a larger hemorrhage. Previous population-based studies have confirmed an association between low TCs and a high incidence of hemorrhagic stroke. It has been established that a TC below 200 decreases the potential for cardiovascular disease. This study suggests that the balance that needs to be achieved between these two extremes presents a unique possibility for an optimal therapeutic range of total cholesterol levels. Materials & methods Inclusion criteria included all adult patients with International Classification of Diseases (ICD)-9/10 code for hemorrhagic stroke, from June 2007 to June 2017. A total of 300 patients met the criteria (N=300). For each patient, the following data were collected: NIH Stroke Scale, TC level, triglyceride level, low-density lipoprotein (LDL) and high-density lipoprotein (HDL), cholesterol reducing medications, size of hemorrhage on computed tomography (CT) of the head, location of hemorrhage, and patient disposition. Statistical analysis was done using the Generalized Linear Modeling with Wald Chi-square as the statistical determinant. Results Intracerebral hemorrhage size is dependent on the intracranial location with brain lobes having larger bleeds. Minimum hemorrhage size was noted in TC 188-196 and this effect was statistically significant independent of location. HDL has a significant independent effect on hemorrhage size with overall minimum bleed occurring in the range of 43-51 mg/dL HDL (98-106 mg/dL for men and 43-51 mg/dL for women). This sex effect within HDL on hemorrhage size is statistically significant. There was a differential effect of HDL dependent on patient race. Asian and black patients had least IPH volume with HDL 70-79 mg/dL, while Hispanic patients had a minimum at 43-51 mg/dL. White patients required a higher HDL, 80-88 mg/dL to minimize the IPH size. The triglyceride level had a statistically significant independent effect on the bleed size with the minimum hemorrhage size occurring in the range of 205-224 mg/dL. This effect was nuanced by patient race with statistically significant minimum IPH size occurring at 144-164 mg/dL for white patients, 124-143 mg/dL for Hispanic and black patients, and 84-103 mg/dL for Asian patients. Post-hospital patient disposition was not significantly affected by any of the above predictor variables. Conclusion This study found TC, HDL and triglycerides in specific ranges are associated with significantly decreased hemorrhage size across all genders and hemorrhage locations. The ranges with the strongest hemorrhage-limiting effect are as follows: TC 188-196 mg/dL, HDL 43-51 mg/dL (98-106 mg/dL for men and 43-51 mg/dL for women), triglycerides 205-224 mg/dL. Lipids both below and above these ranges yield larger bleeds. It also found larger brain areas will have more extensive hemorrhage than smaller brain areas. Future work in this arena should include collaboration with cardiology to determine ideal ranges for both cardio- and neuroprotection as well as a prospective study to validate the applicability of these findings in patient care.
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Affiliation(s)
- Mark Krel
- Neurosurgery, Riverside University Health System Medical Center, Moreno Valley, USA
| | - Dan E Miulli
- Neurosurgery, Riverside University Health System Medical Center, Moreno Valley, USA
| | - Henry Jung
- Neurosurgery, Kaiser Permanente Los Angeles Medical Center, Los Angeles, USA
| | - James G Wiginton
- Neurosurgery, Riverside University Health System Medical Center, Moreno Valley, USA
| | - James Brazdzionis
- Neurosurgery, Riverside University Health System Medical Center, Moreno Valley, USA
| | | | - Silvio Hoshek
- Neurosurgery, Arrowhead Regional Medical Center, Colton, USA
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Cerebral and skin microcirculatory dysfunction in type 1 diabetes. Postepy Dermatol Alergol 2019; 36:44-50. [PMID: 30858778 PMCID: PMC6409882 DOI: 10.5114/ada.2018.81185] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2017] [Accepted: 01/08/2018] [Indexed: 11/17/2022] Open
Abstract
Introduction An increase in cerebral pulsatility index (PI), measured by transcranial Doppler, reflects the presence of cerebral microangiopathy. A decrease in distance between skin capillaries (DISTANCE) and an increase in the ratio between the area of capillaries and total area of examined skin (COVERAGE), revealed by capillaroscopy, reflects skin microangiopathy. However, little is known about the association between the cerebral and skin microvasculature function in patients at risk of microcirculatory dysfunction. Aim To assess PI of the middle cerebral artery by transcranial Doppler and the DISTANCE and COVERAGE of the nailfold capillaries by quantitative capillaroscopy in patients with type 1 diabetes and control subjects without diabetes, and to investigate relationships between these parameters. Material and methods The study group consisted of 51 patients with type 1 diabetes (median age: 37.5 years) and 23 volunteers free from chronic diseases (median age: 37.9 years). Results Median PI was higher in patients than in control subjects (0.82 vs. 0.75; p < 0.01). Median DISTANCE was lower in patients than in control subjects (220.9 µm vs. 239.7 µm; p = 0.03), while median COVERAGE was higher in patients than in control subjects (20.4% vs. 18.3%; p = 0.01). No correlations between PI and DISTANCE or COVERAGE were found, but PI was correlated with patients’ age and diabetes duration. Conclusions In spite of simultaneous presence of cerebral and skin microangiopathy, we found no association between cerebral and skin microvasculature dysfunction. This seems to indicate independent progression of microcirculatory injury in cerebral and peripheral vascular beds.
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Relationship Between HIV Infection, Antiretroviral Therapy, Inflammatory Markers, and Cerebrovascular Endothelial Function Among Adults in Urban China. J Acquir Immune Defic Syndr 2017; 74:339-346. [PMID: 27875362 DOI: 10.1097/qai.0000000000001254] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
BACKGROUND Cerebrovascular risk is increased in people living with HIV infection compared with age-matched uninfected individuals. Cerebrovascular endothelial dysfunction related to antiretroviral therapy (ART) and inflammation may contribute to higher stroke risk in HIV infection. METHODS We compared cerebral vasoreactivity-a measure of cerebrovascular endothelial function assessed by the breath-holding index (BHI) using transcranial Doppler ultrasound-between virologically suppressed Chinese HIV-infected individuals followed in an HIV clinic in Beijing, China, and uninfected controls. We constructed mixed-effects models to evaluate the association of HIV, ART, and inflammatory markers with cerebral vasoreactivity. RESULTS In an unadjusted model, HIV infection was associated with a trend toward lower cerebral vasoreactivity (BHI 1.08 versus 1.26, P = 0.079). In multivariable analyses, cholesterol modified the association between HIV infection and cerebral vasoreactivity (P = 0.015 for interaction). At a lower total cholesterol of 4.15 mmol/L, HIV was associated with lower cerebral vasoreactivity (BHI -0.28, P = 0.019), whereas at a cholesterol of 5.15 mmol/L, the reduction in cerebral vasoreactivity associated with HIV was no longer statistically significant (BHI -0.05, P = 0.64). Among HIV-infected individuals, use of lopinavir/ritonavir compared with efavirenz was associated with lower cerebral vasoreactivity (BHI -0.24, P = 0.040). We did not find a significant association between inflammatory markers and cerebral vasoreactivity. CONCLUSIONS Cerebrovascular endothelial dysfunction associated with HIV infection may be most relevant for individuals with less traditional vascular risk, such as those with lower cholesterol. Further study of the impact of ART on cerebrovascular endothelial function is warranted to aid with ART selection in individuals at high cerebrovascular risk.
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Statin Use and Cognitive Impairment in Patients With Type 1 Diabetes: An Observational Study. Clin Neuropharmacol 2017; 39:182-7. [PMID: 27046662 DOI: 10.1097/wnf.0000000000000158] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
OBJECTIVE We aimed to assess a wide range of cognitive functions in patients with type 1 diabetes (DM1) compared with healthy control subjects and to evaluate the effects of statins on cognitive functions in DM1 patients. MATERIALS AND METHODS The sample studied consisted of 55 DM1 patients (80.0% with hyperlipidemia, 20% with statin treatment) and 36 age-matched control subjects (77.8% with hyperlipidemia) without diabetes or statin use. Their cognitive functions (attention, memory, and executive functions) were evaluated with the trail making test, controlled oral word association test (COWAT), Rey-Osterrieth complex figure test, brain damage test (diagnosticum für cerebralschädigung, DCS), Wisconsin card sorting test (WCST), and digit span and block design tests from the revised Wechsler adult intelligence scale. RESULTS Cognitive performance was impaired in DM1 patients when compared with the control group with regard to semantic verbal fluency (COWAT_animals), visual learning (DCS), conceptual-level responses, executive functions (WCST random errors), and WCST trials to complete the first category. Subgroups of DM1 patients distinguished on the basis of statin therapy did not differ with regard to verbal fluency (COWAT_animals), visual learning (DCS), conceptual-level responses, executive functions (WCST random errors), and WCST trials to complete the first category. Multivariate analysis also does not show the impact of statin therapy on cognitive functioning regardless of the duration of education, microangiopathic evidence, the presence of hyperlipidemia, or antihypertensive therapy. CONCLUSIONS We find impairment of cognitive functions in DM1 patients when compared with control subjects without diabetes. However, we show neither the effect of statins nor the significant influence of metabolic control, microangiopathic complications, or the presence of hyperlipidemia on cognitive functions in DM1 patients.
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The Effect of Chunghyul-Dan on Hyperventilation-Induced Carbon Dioxide Reactivity of the Middle Cerebral Artery in Normal Subjects: A Dose-Dependent Study. EVIDENCE-BASED COMPLEMENTARY AND ALTERNATIVE MEDICINE 2017; 2017:4567217. [PMID: 28512500 PMCID: PMC5415863 DOI: 10.1155/2017/4567217] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/23/2017] [Revised: 03/06/2017] [Accepted: 03/09/2017] [Indexed: 11/21/2022]
Abstract
Background. This study was conducted to show the prompt effect of chunghyul-dan (CHD) on cerebral hemodynamics in order to provide evidence for its use in stroke prevention. Methods. Hyperventilation-induced CO2 reactivity of the middle cerebral artery was measured in 12 healthy male volunteers (mean age: 26.3 ± 1.1 years) using transcranial Doppler sonography. All subjects were examined before and for 3 hours after administration, with an interval of 1 week between measurements. Results. Compared to baseline, the CO2 reactivity of the middle cerebral artery increased significantly at 2 and 3 hours after the administration of CHD (600 mg and 1200 mg). The mean blood pressure and heart rate did not vary from the baseline values in all groups. Conclusion. These data suggest that CHD administration (especially 600 mg) immediately improves cerebral blood flow.
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Chow FC, Boscardin WJ, Mills C, Ko N, Carroll C, Price RW, Deeks S, Sorond FA, Hsue PY. Cerebral vasoreactivity is impaired in treated, virally suppressed HIV-infected individuals. AIDS 2016; 30:45-55. [PMID: 26372478 DOI: 10.1097/qad.0000000000000875] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
OBJECTIVE To compare cerebral vasoreactivity, a measure of cerebrovascular endothelial function, between treated, virally suppressed HIV-infected individuals and HIV-uninfected controls and to evaluate the effect of HIV-specific factors on cerebral vasoreactivity. METHODS Cross-sectional study of 65 antiretroviral therapy-treated, virally suppressed HIV-infected individuals and 28 HIV-uninfected controls. Participants underwent noninvasive assessment of cerebral vasoreactivity using transcranial Doppler ultrasound and inhaled carbon dioxide (CO2). We used mixed effects multivariable linear regression to determine the association of HIV infection and HIV-specific factors with cerebral vasoreactivity. RESULTS Mean age was 57.2 years for HIV-infected participants and 53.5 years for HIV-uninfected controls. Most participants (95%) were men. Twenty-six per cent of HIV-infected participants were nonwhite compared to 32% of controls. Among HIV-infected participants, mean CD4 cell count was 596 cells/μl, and mean duration of viral suppression was 7.8 years. Cerebral vasoreactivity in response to hypercapnia (cerebral VRhyper) was lower in HIV-infected individuals compared to uninfected controls (3.23 versus 3.81%, P = 0.010). After adjusting for demographic and vascular risk factors, HIV infection was independently associated with lower cerebral vasoreactivity (-0.86%, 95% CI -1.30 to -0.42%, P < 0.001). We did not find a statistically significant effect of recent or nadir CD4 cell count on cerebral vasoreactivity. There was a trend toward higher cerebral vasoreactivity for each additional year of viral suppression. CONCLUSION Treated, virally suppressed HIV infection negatively impacted cerebral vasoreactivity even after adjustment for traditional vascular risk factors. These data highlight the potential contribution of cerebrovascular endothelial dysfunction to the elevated risk of stroke observed in HIV-infected individuals.
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Pallebage-Gamarallage M, Takechi R, Lam V, Elahy M, Mamo J. Pharmacological modulation of dietary lipid-induced cerebral capillary dysfunction: Considerations for reducing risk for Alzheimer's disease. Crit Rev Clin Lab Sci 2015; 53:166-83. [PMID: 26678521 DOI: 10.3109/10408363.2015.1115820] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
An increasing body of evidence suggests that cerebrovascular dysfunction and microvessel disease precede the evolution of hallmark pathological features that characterise Alzheimer's disease (AD), consistent with a causal association for onset or progression. Recent studies, principally in genetically unmanipulated animal models, suggest that chronic ingestion of diets enriched in saturated fats and cholesterol may compromise blood-brain barrier (BBB) integrity resulting in inappropriate blood-to-brain extravasation of plasma proteins, including lipid macromolecules that may be enriched in amyloid-β (Aβ). Brain parenchymal retention of blood proteins and lipoprotein bound Aβ is associated with heightened neurovascular inflammation, altered redox homeostasis and nitric oxide (NO) metabolism. Therefore, it is a reasonable proposition that lipid-lowering agents may positively modulate BBB integrity and by extension attenuate risk or progression of AD. In addition to their robust lipid lowering properties, reported beneficial effects of lipid-lowering agents were attributed to their pleiotropic properties via modulation of inflammation, oxidative stress, NO and Aβ metabolism. The review is a contemporary consideration of a complex body of literature intended to synthesise focussed consideration of mechanisms central to regulation of BBB function and integrity. Emphasis is given to dietary fat driven significant epidemiological evidence consistent with heightened risk amongst populations consuming greater amounts of saturated fats and cholesterol. In addition, potential neurovascular benefits associated with the use of hypolipidemic statins, probucol and fenofibrate are also presented in the context of lipid-lowering and pleiotropic properties.
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Affiliation(s)
- Menuka Pallebage-Gamarallage
- a Faculty of Health Sciences , School of Public Health Curtin University , Perth , WA , Australia and.,b Curtin Health Innovation Research Institute of Aging and Chronic Disease, Curtin University , Perth , WA , Australia
| | - Ryusuke Takechi
- a Faculty of Health Sciences , School of Public Health Curtin University , Perth , WA , Australia and.,b Curtin Health Innovation Research Institute of Aging and Chronic Disease, Curtin University , Perth , WA , Australia
| | - Virginie Lam
- a Faculty of Health Sciences , School of Public Health Curtin University , Perth , WA , Australia and.,b Curtin Health Innovation Research Institute of Aging and Chronic Disease, Curtin University , Perth , WA , Australia
| | - Mina Elahy
- a Faculty of Health Sciences , School of Public Health Curtin University , Perth , WA , Australia and.,b Curtin Health Innovation Research Institute of Aging and Chronic Disease, Curtin University , Perth , WA , Australia
| | - John Mamo
- a Faculty of Health Sciences , School of Public Health Curtin University , Perth , WA , Australia and.,b Curtin Health Innovation Research Institute of Aging and Chronic Disease, Curtin University , Perth , WA , Australia
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Nadkarni NK, Perera S, Hanlon JT, Lopez O, Newman AB, Aizenstein H, Elam M, Harris TB, Kritchevsky S, Yaffe K, Rosano C. Statins and brain integrity in older adults: secondary analysis of the Health ABC study. Alzheimers Dement 2015; 11:1202-11. [PMID: 25592659 PMCID: PMC4499493 DOI: 10.1016/j.jalz.2014.11.003] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2014] [Revised: 10/28/2014] [Accepted: 11/06/2014] [Indexed: 12/24/2022]
Abstract
INTRODUCTION We examined whether statins are associated with better cerebral white (WM) and gray matter (GM) indices in community-dwelling elders. METHODS In 295 older adults, we compared white matter hyperintensities (WMH) on brain magnetic resonance imaging and, total WM fractional anisotropy (FA) and GM mean diffusivity (MD) on diffusion tensor imaging, of Alzheimer's disease (AD) relevant regions in statin-exposed and statin-unexposed participants stratified by Modified Mini-Mental Status Examination (3MS) score. RESULTS There was no overall effect of statin exposure on cerebral structural indices. The interaction between statin exposure and 3MS was significant for total-WMH and WM FA (both P < .05) but not GM MD. In the lowest 3MS tertile (mean: 86), statin-exposed individuals had lower total-WMH and higher WM FA (P = .005 and P = .044) and FA of tracts linked to clinical AD (P-value range= .005-.04) despite statistical adjustments. These differences were not significant in the two higher 3MS tertiles. DISCUSSION Statins may benefit WM in older adults vulnerable to dementia.
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Affiliation(s)
- Neelesh K Nadkarni
- Division of Geriatric Medicine and Gerontology - Department of Medicine, University of Pittsburgh - School of Medicine, Pittsburgh, PA, USA.
| | - Subashan Perera
- Division of Geriatric Medicine and Gerontology - Department of Medicine, University of Pittsburgh - School of Medicine, Pittsburgh, PA, USA
| | - Joseph T Hanlon
- Division of Geriatric Medicine and Gerontology - Department of Medicine, University of Pittsburgh - School of Medicine, Pittsburgh, PA, USA; Department of Epidemiology - Graduate School of Public Health, University of Pittsburgh, Pittsburgh, PA, USA
| | - Oscar Lopez
- Department of Neurology, University of Pittsburgh - School of Medicine, Pittsburgh, PA, USA; University of Pittsburgh Alzheimer's Disease Research Center, Pittsburgh, PA, USA
| | - Anne B Newman
- Department of Epidemiology - Graduate School of Public Health, University of Pittsburgh, Pittsburgh, PA, USA
| | - Howard Aizenstein
- Department of Psychiatry, University of Pittsburgh - School of Medicine, Pittsburgh, PA, USA
| | - Marshall Elam
- Department of Medicine, University of Tennessee Health Sciences Center, Memphis, TN, USA
| | - Tamara B Harris
- Laboratory of Epidemiology, Demography, and Biometry, National Institute on Aging, Bethesda, MD, USA
| | - Stephen Kritchevsky
- Department of Gerontology and Geriatrics, Sticht Center on Aging, Wake Forest School of Medicine, Winston-Salem, NC, USA
| | - Kristine Yaffe
- Department of Psychiatry, University of California at San Francisco, San Francisco, CA, USA
| | - Caterina Rosano
- Department of Epidemiology - Graduate School of Public Health, University of Pittsburgh, Pittsburgh, PA, USA
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A novel trigger for cholesterol-dependent smooth muscle contraction mediated by the sphingosylphosphorylcholine-Rho-kinase pathway in the rat basilar artery: a mechanistic role for lipid rafts. J Cereb Blood Flow Metab 2015; 35:835-42. [PMID: 25605290 PMCID: PMC4420858 DOI: 10.1038/jcbfm.2014.260] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/11/2014] [Revised: 12/12/2014] [Accepted: 12/13/2014] [Indexed: 02/04/2023]
Abstract
Hyperlipidemia is a risk factor for abnormal cerebrovascular events. Rafts are cholesterol-enriched membrane microdomains that influence signal transduction. We previously showed that Rho-kinase-mediated Ca(2+) sensitization of vascular smooth muscle (VSM) induced by sphingosylphosphorylcholine (SPC) has a pivotal role in cerebral vasospasm. The goals of the study were to show SPC-Rho-kinase-mediated VSM contraction in vivo and to link this effect to cholesterol and rafts. The SPC-induced VSM contraction measured using a cranial window model was reversed by Y-27632, a Rho-kinase inhibitor, in rats fed a control diet. The extent of SPC-induced contraction correlated with serum total cholesterol. Total cholesterol levels in the internal carotid artery (ICA) were significantly higher in rats fed a cholesterol diet compared with a control diet or a β-cyclodextrin diet, which depletes VSM cholesterol. Western blotting and real-time PCR revealed increases in flotillin-1, a raft marker, and flotillin-1 mRNA in the ICA in rats fed a cholesterol diet, but not in rats fed the β-cyclodextrin diet. Depletion of cholesterol decreased rafts in VSM cells, and prevention of an increase in cholesterol by β-cyclodextrin inhibited SPC-induced contraction in a cranial window model. These results indicate that cholesterol potentiates SPC-Rho-kinase-mediated contractions of importance in cerebral vasospasm and are compatible with a role for rafts in this process.
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Cerebral blood flow velocity and vasomotor reactivity during autonomic challenges in heart failure. Nurs Res 2014; 63:194-202. [PMID: 24785247 DOI: 10.1097/nnr.0000000000000027] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
BACKGROUND Significant alterations in autonomic nervous system (ANS) function, vasomotor reactivity, and cerebral blood flow may develop from damage to brain ANS regulatory areas in heart failure (HF). This preferentially right-sided injury occurs largely in autonomic structures perfused by the middle cerebral artery. Indications of altered, asymmetrical perfusion raise the potential for further neural damage. OBJECTIVE To determine whether the extent of middle cerebral artery blood flow velocity and vasomotor reactivity is altered on one side of the brain over the other in HF versus control subjects, three ANS challenges were administered-each challenge recruited ANS regulatory areas potentially injured in HF. METHODS Transcranial Doppler ultrasonography was used to measure cerebral blood flow velocity and vasomotor reactivity in 40 HF (mean age = 52.7 years, SD = 7.5; 27 men; left ventricular ejection fraction = 26.8, SD = 8.3) and 42 control subjects (mean age = 48.3 years, SD = 6.0; 22 men) during 5% CO2 and hyperventilation, Valsalva, and orthostatic (upper body tilt) challenges. RESULTS Lower cerebral blood flow velocity and abnormal vasomotor reactivity (p < .01) were noted in HF middle cerebral arteries during all challenges. More right-sided flow velocity reductions appeared in HF, with laterality differences noted during CO2 and orthostatic (p < .05), but not Valsalva challenges. DISCUSSION Diminished cerebral blood flow velocity and altered vasomotor reactivity were associated with HF, changes being preferentially on the right side; the asymmetry was more pronounced during CO2 and orthostatic challenges. The impaired blood flow regulation may contribute to the lateralized brain pathology in ANS areas, undermining autonomic control in HF.
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Mihos CG, Pineda AM, Santana O. Cardiovascular effects of statins, beyond lipid-lowering properties. Pharmacol Res 2014; 88:12-9. [PMID: 24631782 DOI: 10.1016/j.phrs.2014.02.009] [Citation(s) in RCA: 99] [Impact Index Per Article: 9.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/27/2013] [Revised: 02/25/2014] [Accepted: 02/27/2014] [Indexed: 12/11/2022]
Abstract
The 3-hydroxy-3-methylglutaryl-coenzyme A reductase inhibitors, better known as 'statins', are amongst the most widely used medications in the world. They have become a pivotal component in the primary and secondary prevention of coronary artery and vascular disease. However, a growing amount of evidence has suggested that statins also possess strong pleiotropic effects irrespective of their lipid-lowering properties, which include enhancement of endothelial function, anti-inflammatory and anti-atherothrombotic properties, and immunomodulation. The following provides a comprehensive and updated review of the clinical evidence regarding the pleiotropic effects of statins in cardiovascular disorders and their potential therapeutic benefits.
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Affiliation(s)
- Christos G Mihos
- Columbia University, Division of Cardiology at the Mount Sinai Heart Institute, Miami Beach, FL, United States
| | - Andres M Pineda
- Columbia University, Division of Cardiology at the Mount Sinai Heart Institute, Miami Beach, FL, United States
| | - Orlando Santana
- Columbia University, Division of Cardiology at the Mount Sinai Heart Institute, Miami Beach, FL, United States.
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Abstract
HMG-CoA reductase inhibitors (statins) are associated with improved stroke outcome. This observation has been attributed in part to the palliative effect of statins on cerebral hemodynamics and cerebral autoregulation (CA), which are mediated mainly through the upregulation of endothelium nitric oxide synthase (eNOS). Several animal studies indicate that statin pretreatment enhances cerebral blood flow after ischemic stroke, although this finding is not further supported in clinical settings. Cerebral vasomotor reactivity, however, is significantly improved after long-term statin administration in most patients with severe small vessel disease, aneurysmal subarachnoid hemorrhage, or impaired baseline CA.
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Ebinger M, Brunecker P, Schultze-Amberger J, Gertz K, Müller B, Fiebach JB, Dichgans M, Endres M. Statins and Cerebral Perfusion in Patients with Leukoaraiosis – a Translational Proof-of-Principal MRI Study. Int J Stroke 2012; 7:E5. [DOI: 10.1111/j.1747-4949.2012.00807.x] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Affiliation(s)
- Martin Ebinger
- Center for Stroke Research Berlin (CSB), Berlin, Germany
- Klinik und Hochschulambulanz für Neurologie, Charité – Universitätsmedizin Berlin, Berlin, Germany
| | | | | | - Karen Gertz
- Klinik und Hochschulambulanz für Neurologie, Charité – Universitätsmedizin Berlin, Berlin, Germany
| | - Bianca Müller
- Klinik und Hochschulambulanz für Neurologie, Charité – Universitätsmedizin Berlin, Berlin, Germany
| | | | | | - Matthias Endres
- Center for Stroke Research Berlin (CSB), Berlin, Germany
- Klinik und Hochschulambulanz für Neurologie, Charité – Universitätsmedizin Berlin, Berlin, Germany
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Yanuck D, Mihos CG, Santana O. Mechanisms and Clinical Evidence of the Pleiotropic Effects of the Hydroxy-Methyl-Glutaryl-CoA Reductase Inhibitors in Central Nervous System Disorders: A Comprehensive Review. Int J Neurosci 2012; 122:619-29. [DOI: 10.3109/00207454.2012.704455] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
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Huq R, Philbey CE, Mistri AK, Panerai RB, Robinson TG. Dynamic cerebral autoregulation assessed by respiratory manoeuvres in non-insulin-treated Type 2 diabetes mellitus. Diabet Med 2012; 29:609-13. [PMID: 22004530 DOI: 10.1111/j.1464-5491.2011.03497.x] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
AIMS This study investigated dynamic cerebral autoregulation in Type 2 diabetes, where dynamic cerebral autoregulation may be impaired as a consequence of microvascular changes and/or autonomic neuropathy. METHODS Eleven healthy control subjects and 11 age- and sex-matched patients with Type 2 diabetes controlled with lifestyle modifications or oral anti-diabetes treatment were recruited. Dynamic cerebral autoregulation was calculated by the autoregressive moving average autoregulatory index from a continuous blood pressure and R-R interval (time between each ventricular systole) recording. End-tidal carbon dioxide was also monitored and changes in response to breath holding and hyperventilation as a metabolic stimulus were measured. RESULTS No significant differences were seen in cerebral blood flow velocity at baseline, or in response to breath holding between people with diabetes and control subjects, although the cerebral blood flow velocity response associated with hyperventilation was significantly reduced in the diabetes group. No significant differences in dynamic cerebral autoregulation were seen at baseline or in response to respiratory manoeuvres between the groups. CONCLUSIONS Dynamic cerebral autoregulation is not impaired in patients with Type 2 diabetes, although a small difference could not be excluded as the study was only powered to detect an autoregulatory index difference > 2 units. Further study in a larger population with a spectrum of disease severity may reveal clinically important differences.
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Affiliation(s)
- R Huq
- Ageing and Stroke Medicine Medical Physics Groups, Department of Cardiovascular Sciences, University of Leicester, Leicester, UK
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Chugh C, Lee JM, Biller J. Memory loss, behavioral changes, and slurred speech in a 49-year-old man. Front Neurol 2011; 2:27. [PMID: 21562603 PMCID: PMC3087163 DOI: 10.3389/fneur.2011.00027] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2011] [Accepted: 04/07/2011] [Indexed: 11/24/2022] Open
Abstract
A 49-year-old man presented with slurred speech, memory loss, and behavioral changes. His clinical course was marked by decline in functional status and cognition. He had poorly controlled hypertension and hyperlipidemia. Neuroimaging was remarkable for multiple subcortical white matter lesions. We discuss the diagnostic and therapeutic approach of rapidly progressing cognitive decline in the given clinical setting.
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Affiliation(s)
- Chandril Chugh
- Department of Neurology, Stritch School of Medicine, Loyola University Chicago Maywood, IL, USA
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Mihos CG, Santana O. Pleiotropic effects of the HMG-CoA reductase inhibitors. Int J Gen Med 2011; 4:261-71. [PMID: 21556312 PMCID: PMC3085235 DOI: 10.2147/ijgm.s16779] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2011] [Indexed: 12/19/2022] Open
Abstract
The HMG-CoA reductase inhibitors (statins) are used extensively in the treatment of hyperlipidemia. They have also demonstrated a benefit in a variety of other disease processes. These secondary actions are known as pleiotropic effects. Our paper serves as a focused and updated discussion on the pleiotropy of statins and emphasizes the importance of randomized placebo-controlled trials to further elucidate this interesting phenomenon.
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Affiliation(s)
- Christos G Mihos
- Columbia University Division of Cardiology, Mount Sinai Heart Institute, Miami Beach, FL, USA
| | - Orlando Santana
- Columbia University Division of Cardiology, Mount Sinai Heart Institute, Miami Beach, FL, USA
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Farhoudi M, Mehrvar K, Aslanabadi N, Ghabili K, Baghmishe NR, Ilkhchoei F. Doppler study of cerebral arteries in hypercholesterolemia. Vasc Health Risk Manag 2011; 7:203-7. [PMID: 21490946 PMCID: PMC3072744 DOI: 10.2147/vhrm.s18663] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2011] [Indexed: 11/30/2022] Open
Abstract
Background: Hypercholesterolemia is one of the major modifiable risk factors for atherosclerosis of the coronary and carotid arteries. Although transcranial Doppler (TCD) studies of the cerebral arteries are indicative of decreased cerebral blood flow velocities in patients with hypercholesterolemia, the number of these studies has been limited. The aim of this study was to assess the hemodynamic status of the cerebral arteries in patients with hypercholesterolemia using TCD. Methods: In a case-control study, 60 individuals, including 30 hypercholesterolemic cases (low-density lipoprotein [LDL] > 160 mg/dL) and 30 healthy controls were enrolled. Other arterial risk factors, including diabetes mellitus, hypertension, smoking, and obesity (body mass index > 30), were evaluated and matched as well. TCD was used to assess the hemodynamics of the intracranial arteries as well as the internal carotid arteries. The mean blood flow velocity, pulsatility index, and resistance index were recorded in all the arteries. Results: The mean blood flow velocity, pulsatility index, and resistance index of the intracranial arteries and internal carotid arteries were not significantly different between the two groups (P > 0.05). However, those with higher levels of LDL (>180 mg/dL) showed significantly lower mean blood flow velocity and resistance index of the internal carotid arteries than the healthy controls. In addition, individuals with high-density lipoprotein (HDL) <35 mg/dL had significantly lower mean blood flow velocity in the internal carotid arteries. Conclusion: Hypercholesterolemia (LDL >160 mg/dL) does not seem to have a detrimental effect on the hemodynamic status of the intracranial arteries and internal carotid arteries. However, in cases of higher LDL (>180 mg/dL) and lower HDL, decreased TCD parameters in the internal carotid arteries, as a surrogate of the peripheral arteries, are prominent.
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Affiliation(s)
- Mehdi Farhoudi
- Neuroscience Research Center, Tabriz University of Medical Sciences, Tabriz, Iran
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Forteza A, Romano JG, Campo-Bustillo I, Campo N, Haussen DC, Gutierrez J, Koch S. High-dose atorvastatin enhances impaired cerebral vasomotor reactivity. J Stroke Cerebrovasc Dis 2011; 21:487-92. [PMID: 21334223 DOI: 10.1016/j.jstrokecerebrovasdis.2010.12.002] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2010] [Revised: 11/18/2010] [Accepted: 12/01/2010] [Indexed: 11/25/2022] Open
Abstract
The influence of statin therapy on cerebral vasomotor function has not been fully characterized. We report the effects of high-dose atorvastatin therapy on cerebral vasomotor reactivity (VMR) in patients with controlled hypertension and dyslipidemia. We prospectively enrolled 36 patients with controlled hypertension and a low-density lipoprotein (LDL) cholesterol concentration >100 mg/dL. Atorvastatin 80 mg was given daily for 6 months and then discontinued. VMR was assessed by hypercapnic and hypocapnic transcranial Doppler challenge in both the right and left middle cerebral artery (MCA) at baseline, and after 3 and 6 months of therapy. Forty-five days after statin cessation, a repeat VMR was performed. VMR impairment was defined as ≤70%. Blood pressure, lipid levels, liver function, and creatine kinase level were monitored. Mean patient age was 60 years, 16 were men, and 13 had a previous history of subcortical infarction. Mean LDL cholesterol level before treatment was 154 ± 30 mg/dL. Atorvastatin lowered LDL by 53% at 3 months and by 46% at 6 months. Baseline VMR was 71% ± 21% in the right MCA and 70% ± 19% in the left MCA. No significant effect of atorvastatin on VMR was seen at 3 months and 6 months in the study population as a whole. In the subgroup of patients with baseline VMR impairment, atorvastatin therapy was associated with significantly improved VMR at both 3 and 6 months. This effect persisted for at least 45 days after discontinuation of therapy. Our findings indicate that high-dose atorvastatin therapy can significantly improve impaired cerebral VMR, and that the effects of atorvastatin on VMR persist for 1.5 months after discontinuation of therapy. We found no benefit of atorvastatin therapy in patients with preserved baseline vasoreactivity.
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Affiliation(s)
- Alejandro Forteza
- Cardiac and Stroke Institute, Jackson Memorial Hospital, Miami, Florida, USA.
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Lee JY, Lee YS. Vasomotor reactivity in middle cerebral artery stenosis. J Neurol Sci 2011; 301:35-7. [PMID: 21112599 DOI: 10.1016/j.jns.2010.11.008] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2010] [Revised: 11/09/2010] [Accepted: 11/09/2010] [Indexed: 10/18/2022]
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Reinhard M, Guschlbauer B, Olschewski M, Weiller C, Hetzel A. Improvement of exhausted cerebral vasoreactivity in carotid occlusion: benefit of statins? J Neurol 2010; 258:791-4. [PMID: 21116824 DOI: 10.1007/s00415-010-5840-9] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2010] [Revised: 11/01/2010] [Accepted: 11/11/2010] [Indexed: 10/18/2022]
Abstract
In internal carotid artery occlusion (ICAO), a spontaneous increase of cerebral vasoreactivity (CVR) may occur over time. Statins are known to increase CVR. We analyzed the influence of statin treatment and other cofactors on CVR improvement in patients with ICAO. Sixty-six patients with ICAO were reexamined after 15 ± 6 months. CVR in both middle cerebral arteries was assessed by transcranial Doppler and inhalation of 7% CO(2). Pre-defined cut-off values were used to define exhausted CVR. Cofactors analyzed were: age, sex, hypertension, diabetes, statin treatment, degree of contralateral stenosis, quality of intracranial collateral flow, duration of ICAO. Mean CVR did not differ between the two studies. Twenty patients had exhausted CVR at baseline, 11 of them improved above the cut-off at follow-up (55%). Factors significantly associated with this improvement were good collateral pattern at baseline (p = 0.0065) and statin treatment (p = 0.0179). Odds ratios for improving CVR were 36.0 [95% CI 2.7-476.3] for good collateral flow and 20.0 [95% CI 1.7-238.6] for statin treatment. In conclusion, exhausted CVR frequently improves during the course of ICAO. Good collateral function and statin treatment are significantly associated with improving CVR.
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Affiliation(s)
- Matthias Reinhard
- Department of Neurology, Neurocenter, University of Freiburg, Freiburg, Germany.
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The Pleiotropic Effects of the Hydroxy-Methyl-Glutaryl-CoA Reductase Inhibitors in Cardiovascular Disease. Cardiol Rev 2010; 18:298-304. [DOI: 10.1097/crd.0b013e3181f52a7f] [Citation(s) in RCA: 72] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
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Kozera GM, Dubaniewicz M, Zdrojewski T, Madej-Dmochowska A, Mielczarek M, Wojczal J, Chwojnicki K, świerblewska E, Schminke U, Wyrzykowski B, Nyka WM. Cerebral vasomotor reactivity and extent of white matter lesions in middle-aged men with arterial hypertension: a pilot study. Am J Hypertens 2010; 23:1198-203. [PMID: 20651697 DOI: 10.1038/ajh.2010.152] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Abstract
BACKGROUND Cerebrovascular reactivity (CVR) impairment and cerebral white matter lesions (WMLs) are associated in elderly or patients with overt cerebral ischemia. Such association has not been confirmed for asymptomatic middle-aged individuals with risk factors for stroke. We assessed the relationship between the CVR and the presence of WMLs in a middle-aged population-based cohort of hypertensive men. METHODS Magnetic resonance imaging (MRI) and transcranial Doppler (TCD) examination were performed in 54 hypertensive men, all at 60 years of age, without a history of stroke, neurologic deficits, or carotid stenosis. The CVR of the middle cerebral artery (MCA) was expressed as the vasomotor reactivity reserve (VMRr). RESULTS WMLs were detected in 22 men (40.7%); all WMLs were classified as mild (first grade of the Fazekas modified scale). The VMRr was lower in patients with WMLs (mean 55%; s.e. 3%) compared to those without WMLs (mean 65%; s.e. 3%; P = 0.03). The lower VMRr in patients with WMLs was consistent after controlling for confounders. A higher pulsatility index (PI) in subjects with WMLs (mean 1.08; s.e. 0.05) compared to those without WMLs (mean 0.90; s.e. 0.05; P = 0.01) was not consistent after controlling for confounders. CONCLUSIONS The CVR was lower in middle-aged hypertensive men with WMLs compared to those without WMLs indicating that even a low load of WMLs may reflect some functional impairment of the cerebral microvasculature.
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Willey JZ, Elkind MSV. 3-Hydroxy-3-methylglutaryl-coenzyme A reductase inhibitors in the treatment of central nervous system diseases. ACTA ACUST UNITED AC 2010; 67:1062-7. [PMID: 20837848 DOI: 10.1001/archneurol.2010.199] [Citation(s) in RCA: 53] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
3-Hydroxy-3-methylglutaryl-coenzyme A (HMG-CoA) reductase inhibitors (statins) are among the most prescribed medications in the United States. Statins act on the rate-limiting step in cholesterol biosynthesis (the conversion of HMG-CoA to mevalonate) and are effective in treating dyslipidemia. However, statins decrease other downstream products of the mevalonate pathway, and it is via these pathways that statins may affect inflammation, nitric oxide synthesis, the coagulation cascade, and other processes. Through these pleiotropic effects, statins may have an effect on neurologic diseases, including ischemic and hemorrhagic stroke, Alzheimer disease, Parkinson disease, and multiple sclerosis. This article reviews the basic biochemistry of statins as it relates to these pleiotropic effects, the potential role of statins in several neurologic disorders, and the results of clinical trials performed for several of these conditions.
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Affiliation(s)
- Joshua Z Willey
- Department of Neurology, Columbia University, New York, NY 10032, USA.
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Yamashiro K, Milsom AB, Duchene J, Panayiotou C, Urabe T, Hattori N, Ahluwalia A. Alterations in nitric oxide and endothelin-1 bioactivity underlie cerebrovascular dysfunction in ApoE-deficient mice. J Cereb Blood Flow Metab 2010; 30:1494-503. [PMID: 20234380 PMCID: PMC2949246 DOI: 10.1038/jcbfm.2010.34] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
Hypercholesterolemia is associated with decreased nitric oxide (NO) bioavailability and endothelial dysfunction, a phenomenon thought to have a major role in the altered cerebral blood flow evident in stroke. Therefore, strategies that increase endothelial NO production have potential utility. Vascular reactivity of the middle cerebral artery (MCA) from C57BL/6J wild-type (WT) mice, apolipoprotein-E knockout (ApoE(-/-)) mice, and mice treated with the phosphodiesterase inhibitor cilostazol (100 mg/kg) was analyzed using the tension myograph. Contractile responses to endothelin-1 were significantly enhanced in MCA from ApoE(-/-) mice compared with WT mice (P<0.01), an effect absent in cilostazol-treated ApoE(-/-) mice. Acetylcholine-induced relaxation (which is entirely NO-dependent) was significantly impaired in MCA of ApoE(-/-) mice compared with WT mice (P<0.05), again an effect prevented by cilostazol treatment. Endothelial NOS phosphorylation at Ser(1179) was decreased in the aorta of ApoE(-/-) mice compared with WT mice (P<0.05), an effect normalized by cilostazol. Taken together, our data suggest that the endothelial dysfunction observed in MCA associated with hypercholesterolemia is prevented by cilostazol, an effect likely due to the increase in eNOS phosphorylation and, therefore, activity.
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Affiliation(s)
- Kazuo Yamashiro
- Clinical Pharmacology, William Harvey Research Institute, Barts and The London School of Medicine and Dentistry, Charterhouse Square, London, UK
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Wang Q, Yan J, Chen X, Li J, Yang Y, Weng J, Deng C, Yenari MA. Statins: multiple neuroprotective mechanisms in neurodegenerative diseases. Exp Neurol 2010; 230:27-34. [PMID: 20406638 DOI: 10.1016/j.expneurol.2010.04.006] [Citation(s) in RCA: 104] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2010] [Accepted: 04/12/2010] [Indexed: 01/16/2023]
Abstract
Statins have been widely used for the treatment of a variety of conditions beyond their original role in lowering cholesterol. Since statins have relatively few side effects, they have been recognized as useful medicine to ameliorate neurodegenerative disorders. Current studies on the applications of statins have demonstrated their neuroprotective and clinical significance among neurodegenerative diseases like cerebral ischemic stroke, vascular dementia, Alzheimer's disease, and Parkinson's disease, though the neuroprotective mechanisms are not completely understood. This review will discuss recent development in the use of statins in slowing down the progression of these neurodegenerative diseases. It will summarize the potential mechanisms for statin-mediated neuroprotective effects in neurodegenerative diseases. In detail, this review discuss the roles of statins in lowering cholesterol, reducing reactive oxygen species, impairing β-amyloid production and serum apolipoprotein E levels, enhancing the levels of endothelial nitric oxide synthase and cerebral blood flow, and modulating cognitive related receptors and matrix metalloproteases. Finally, different alterations of various receptors in brain regions following statin treatment and their correlations with cognitive dysfunction in Parkinson's disease will also be reviewed, as well as the potential for therapy in ameliorating the progression of Parkinson's disease. This article is part of a Special Issue entitled "Interaction between repair, disease, & inflammation."
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Affiliation(s)
- Qing Wang
- Department of Neurology, The Third Affiliated Hospital of Sun Yat-Sen University, 600 Tianhe Road, Guangzhou, Guangdong 510630, PR China.
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Dawson J, Quinn TJ, Harrow C, Lees KR, Walters MR. The effect of allopurinol on the cerebral vasculature of patients with subcortical stroke; a randomized trial. Br J Clin Pharmacol 2010; 68:662-8. [PMID: 19916990 DOI: 10.1111/j.1365-2125.2009.03497.x] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
AIMS New preventative strategies for stroke are required. One promising strategy is uric acid reduction and xanthine oxidase inhibition with allopurinol. We sought to investigate whether allopurinol improves cerebrovascular reactivity (CVR) following subcortical stroke. METHODS We performed a randomized, double-blind, controlled study to investigate the effect of a 3-month course of 300 mg allopurinol once daily vs. placebo on CVR in individuals with recent (within 6 months) subcortical stroke. Participants were randomized on a 1:1 basis. CVR was defined as the percentage change in middle cerebral artery flow velocity following an intravenous injection of 15 mg kg(-1) of acetazolamide. Our primary end-point was the CVR difference between baseline and 3 months. Secondary end-points included measures of peripheral vascular reactivity and blood markers of inflammation and endothelial activation. RESULTS We enrolled 50 participants; 45 completed the protocol. Baseline serum urate was 0.35 mmol l(-1) (SD 0.1) and 0.34 mmol l(-1) (SD 0.1) in the allopurinol and placebo groups, respectively. There were no serious adverse events related to treatment. CVR did not change following treatment with allopurinol [median CVR change 0.89% after allopurinol (n = 20) and -0.68% after placebo (n = 25); 95% confidence interval for estimated difference in medians -13.4, 25.5, P = 0.64]. Urate was significantly lowered by allopurinol but no change in other secondary end-points was seen. CONCLUSION Xanthine oxidase inhibition with allopurinol has previously been shown to improve cerebrovascular function, but no benefit was seen in this study. It may therefore be that previous encouraging findings will not translate into important clinical benefits.
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Affiliation(s)
- Jesse Dawson
- Acute Stroke Unit, Division of Cardiovascular and Medical Sciences, Faculty of Medicine, University of Glasgow, Western Infirmary, Glasgow, UK.
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Lemke H, de Castro AGC, Schlattmann P, Heuser I, Neu P. Cerebrovascular reactivity over time-course - from major depressive episode to remission. J Psychiatr Res 2010; 44:132-6. [PMID: 19656526 DOI: 10.1016/j.jpsychires.2009.06.010] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/29/2008] [Revised: 06/29/2009] [Accepted: 06/30/2009] [Indexed: 10/20/2022]
Abstract
INTRODUCTION Depression is a prospective risk factor for stroke. Little is known, however, about the pathophysiologic links leading to this association. Cerebrovascular reactivity (CVR) reflects the compensatory dilatory capacity of cerebral arterioles to a dilatory stimulus and is an important mechanism to provide constant cerebral blood flow. In the absence of major arterial stenosis, an impaired CVR has been associated with a higher risk of stroke. We hypothesized that CVR might be continuously reduced in patients with major depression even after successful remission thus contributing to the association between depression and stroke. MATERIALS AND METHODS We investigated CVR in a group of patients (N=29) in the acute episode of depressive illness and after 21months under euthymic condition. A healthy control group (N=33) was investigated at comparable time intervals. All patients and controls were otherwise healthy. CVR was investigated by calculating the increase in cerebral blood flow velocity after stimulation with acetazolamide. Blood flow velocities were measured by transcranial doppler ultrasound. RESULTS A group of acutely depressed patients presented a significantly reduced CVR compared to controls. On follow-up 21months later after treatment and remission, CVR in the patient group had significantly improved, whereas CVR in the control group remained unchanged. Confounding factors had no significant influence. DISCUSSION CVR is impaired during major depression. Since CVR seems to improve after treatment of depression, the contribution to an increased stroke risk among depressive patients may be true for a subgroup only and needs to be further investigated.
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Affiliation(s)
- Harald Lemke
- Department of Psychiatry, Charité Berlin, Campus Benjamin Franklin, 14050 Berlin, Germany
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Salat D, Ribosa R, Garcia-Bonilla L, Montaner J. Statin use before and after acute ischemic stroke onset improves neurological outcome. Expert Rev Cardiovasc Ther 2010; 7:1219-30. [PMID: 19814665 DOI: 10.1586/erc.09.52] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
The devastating consequences of stroke, both in terms of morbidity and mortality, and the economic implications it has worldwide, coupled with a growing knowledge regarding its pathophysiology, has led to the development of novel therapeutic strategies in recent years that have had an enormous impact on clinical practice and the outcome of stroke patients. While thrombolysis is regarded as the most important of these developments, its relatively narrow therapeutic window and complexity of administration imply that only a minority of stroke patients can benefit from it. Among other strategies, in an attempt to overcome this limitation, research has focused on the development of neuroprotection aimed to salvage ischemic brain tissue by means complementary to reperfusion. Among these approaches, the use of statins stands out, which, by inhibiting the HMG CoA reductase, interfere with the formation of isoprenoid intermediates in the biosynthesis of cholesterol, and have been shown to have a positive impact in both the incidence and outcome of acute stroke. The main results of animal models, observational studies, clinical trials and opinion articles available in the medical literature covering the effect of statins on acute brain ischemia will be reviewed in order to provide in-depth information regarding their mode of action and current evidence regarding their potential benefits for ischemic stroke patients.
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Affiliation(s)
- David Salat
- Neurovascular Research Laboratory, Neurovascular Unit, Institut de Recerca, Hospital Vall d'Hebron, Pg Vall d'Hebron 119-129, 08035 Barcelona, Spain
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Bek S, Kaşikçi T, Koç G, Genç G, Demirkaya Ş, Gökçil Z, Odabaşi Z. Cerebral vasomotor reactivity in epilepsy patients. J Neurol 2009; 257:833-8. [DOI: 10.1007/s00415-009-5428-4] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2009] [Revised: 11/21/2009] [Accepted: 12/14/2009] [Indexed: 01/13/2023]
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Carotid endarterectomy improves cerebrovascular reserve capacity preferentially in patients with preoperative impairment as indicated by asymmetric BOLD response to hypercapnia. Eur J Vasc Endovasc Surg 2009; 38:546-51. [PMID: 19744868 DOI: 10.1016/j.ejvs.2009.06.010] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2009] [Accepted: 06/14/2009] [Indexed: 11/24/2022]
Abstract
PURPOSE In patients with symptomatic carotid artery disease the predominant mechanism causing ischaemic injury is considered to be thromboembolic, however compromise of cerebral haemodynamics is considered to be a significant factor. Removal of the embolic source is accepted as the major benefit from carotid endarterectomy (CEA), however improvement in cerebral haemodynamics may be another beneficial outcome as suggested by transcranial doppler (TCD). Blood oxygen level-dependent (BOLD) hypercapnia functional magnetic resonance imaging (fMRI) can be used to map the cerebrovascular reserve (CVR). The aim of this study was to assess the effects of carotid surgery on cerebral haemodynamics in patients with carotid artery disease using a hypercapnia BOLD fMRI and assessment of hemispheric asymmetry. MATERIALS AND METHODS Seventeen patients with symptomatic internal carotid artery stenosis were scanned using a clinical 1.5T MR scanner. Scanning was done immediately prior to and between 4 and 8 weeks after CEA. 10% carbon dioxide was administered to achieve transient episodes of hypercapnia. The data was analyzed using FMRIB Software Library (FSL) software to derive percentage signal change (PSC) for the grey matter of the middle cerebral artery (MCA-GM) territory for both hemispheres. MCA-GM PSC was furthermore normalized to the contralateral hemisphere to derive an Hemispheric Asymmetry Index (hAI) for all patients pre- and postoperatively. RESULTS Ipsilateral GM CVR improved significantly following CEA (2.47% preoperatively vs. 2.73% postoperatively, p=0.038). There was no change in CVR in the contralateral grey and white matter MCA territories (p=0.27, p=0.1). Also, the hAI was significantly more shifted to the ipsilateral hemisphere after CEA (preoperative hAI -0.56, vs. -3.90 postoperatively, p=0.02). Patients with an impaired hAI preoperatively were found to show the greatest improvement in PSC and hAI following CEA (p=0.007). CONCLUSIONS CEA resulted in improved CVR in patients with carotid artery disease as shown by the absolute and hemispheric asymmetry of BOLD response to hypercapnia.. These findings show that benefits from recanalisation may go beyond removal of the embolic source, by improving the cerebrovascular reserve. Moreover, hypercapnia BOLD fMRI may be a useful clinical tool in predicting this therapeutic potential in patients with severe carotid artery disease.
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Abstract
Stroke is the major cause of disability in the Western world and is the third greatest cause of death, but there are no widely effective treatments to prevent the devastating effects of stroke. Extensive and growing evidence implicates inflammatory and immune processes in the occurrence of stroke and particularly in the subsequent injury. Several inflammatory mediators have been identified in the pathogenesis of stroke including specific cytokines, adhesion molecules, matrix metalloproteinases, and eicosanoids. An early clinical trial suggests that inhibiting interleukin-1 may be of benefit in the treatment of acute stroke.
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Kozera GM, Wolnik B, Kunicka KB, Szczyrba S, Wojczal J, Schminke U, Nyka WM, Bieniaszewski L. Cerebrovascular reactivity, intima-media thickness, and nephropathy presence in patients with type 1 diabetes. Diabetes Care 2009; 32:878-82. [PMID: 19228874 PMCID: PMC2671100 DOI: 10.2337/dc08-1805] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
OBJECTIVE Cerebrovascular reactivity impairment was reported as a marker of cerebral microangiopathy in long-term type 1 diabetes. Intima-media complex thickening reflects early stages of macroangiopathy in type 1 diabetes. The analysis of the relationship between these variables and other microangiopathic complications might serve as a beneficial indicator for early prophylaxis in these patients. RESEARCH DESIGN AND METHODS Vasomotor reactivity reserve (VMRr) and breath-holding index (BHI) of the middle cerebral artery were measured with transcranial Doppler in 59 patients (median age 32.0 years, range 20-51, 36 females) with type 1 diabetes, without history of cerebrovascular events, and 30 healthy control subjects (median age 31.5 years, range 25-39, 15 females). The relationships between the presence of selected vascular complications of type 1 diabetes and biochemical parameters, intima-media thickness (IMT), and VMRr and BHI in patients were analyzed. RESULTS VMRr and BHI were lower in patients with type 1 diabetes when compared with healthy subjects (81.5 vs. 100%, P < 0.01, and 1.6 vs. 2.2, P = 0.04, respectively), whereas IMT was significantly higher in patients then in healthy control subjects (0.36 vs. 0.30 mm, P = 0.001). However, no association of IMT with VMRr was found. We found a significant reduction of VMRr and BHI in patients with diabetic nephropathy. CONCLUSIONS The presence of diabetic nephropathy, but not IMT, can be regarded as an indicator of cerebral microangiopathy severity in patients with type 1 diabetes.
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Affiliation(s)
- Grzegorz M Kozera
- Department of Neurology, Medical University of Gdask, Gdask, Poland.
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Toda N, Ayajiki K, Okamura T. Cerebral Blood Flow Regulation by Nitric Oxide: Recent Advances. Pharmacol Rev 2009; 61:62-97. [DOI: 10.1124/pr.108.000547] [Citation(s) in RCA: 268] [Impact Index Per Article: 17.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023] Open
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Lorenz MW, Loesel N, Thoelen N, Gonzalez M, Lienerth C, Dvorak F, Rölz W, Humpich M, Sitzer M. Effects of poor bone window on the assessment of cerebral autoregulation with transcranial Doppler sonography - a source of systematic bias and strategies to avoid it. J Neurol Sci 2009; 283:49-56. [PMID: 19268307 DOI: 10.1016/j.jns.2009.02.329] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
BACKGROUND The consequences of poor insonation conditions on autoregulation parameters assessed with transcranial Doppler (TCD) are unclear. METHODS We present two new complementary methods to assess the quality of a TCD signal. Inserting a thin aluminium foil between TCD probe and skin makes a simple model to artificially worsen a good insonation window. Validation studies are presented. We assessed insonation quality and cerebral autoregulation parameters with transfer function analysis and cross correlation in 46 healthy volunteers with and without the aluminium foil model. The same studies were operated on 45 patients with good insonation windows, naïve, after worsening the bone window and during constant infusion of an ultrasound contrast agent. For studying reproducibility, we assessed autoregulation twice in 30 patients with poor bone windows, with and without constant contrast infusion. RESULTS Both methods to measure insonation quality are valid and reproducible. The aluminium foil model realistically simulates a natural poor bone window, reducing the signal quality (e.g. energy of the signal spectrum from 33.4+/-3.5 to 26.2+/-2.5 dB, p<0.001). Thereby, the autoregulation parameters are systematically biased (e.g. phase difference from 37.3+/-10.1 degrees to 25.9+/-15.1 degrees , p<0.001); while with the use of an ultrasound contrast agent this can be largely compensated (phase difference 35.7+/-10.7 degrees , p<0.001). The reproducibility is significantly improved (ICC from 0.76 to 0.90, p<0.05). CONCLUSIONS Poor bone windows can cause considerable bias in TCD autoregulation parameters. This bias might be avoided by the use of ultrasound contrast agents, which may greatly improve the credibility of TCD autoregulation assessment in elderly patients.
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Affiliation(s)
- Matthias W Lorenz
- Department of Neurology, Johann Wolfgang Goethe-University, Frankfurt am Main, Germany.
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Effects of statins on the progression of cerebral white matter lesion. J Neurol 2009; 256:750-7. [DOI: 10.1007/s00415-009-5008-7] [Citation(s) in RCA: 63] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2008] [Revised: 11/25/2008] [Accepted: 12/03/2008] [Indexed: 10/21/2022]
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Martínez-Sánchez P, Rivera-Ordóñez C, Fuentes B, Ortega-Casarrubios MA, Idrovo L, Díez-Tejedor E. The beneficial effect of statins treatment by stroke subtype. Eur J Neurol 2009; 16:127-33. [DOI: 10.1111/j.1468-1331.2008.02370.x] [Citation(s) in RCA: 40] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Gommer ED, Staals J, van Oostenbrugge RJ, Lodder J, Mess WH, Reulen JPH. Dynamic cerebral autoregulation and cerebrovascular reactivity: a comparative study in lacunar infarct patients. Physiol Meas 2008; 29:1293-303. [DOI: 10.1088/0967-3334/29/11/005] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
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