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Youssef H, Demirer M, Middlebrooks EH, Anisetti B, Meschia JF, Lin MP. Framingham Stroke Risk Profile Score and White Matter Disease Progression. Neurologist 2024; 29:259-264. [PMID: 38867496 DOI: 10.1097/nrl.0000000000000567] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/14/2024]
Abstract
OBJECTIVES To evaluate the relationship between Framingham Stroke Risk Profile (FSRP) score and rate of white matter hyperintensity (WMH) progression and cognition. METHODS Consecutive patients enrolled in the Mayo Clinic Florida Familial Cerebrovascular Diseases Registry (2011-2020) with 2 brain-MRI scans at least 1 year apart were included. The primary outcome was annual change in WMH volume (cm 3 /year) stratified as fast versus slow (above vs. below median). Cognition was assessed using a Mini-Mental State Exam (MMSE, 0-30). FSRP score (0 to 8) was calculated by summing the presence of age 65 years or older, smoking, systolic blood pressure greater than 130 mmHg, diabetes, coronary disease, atrial fibrillation, left ventricular hypertrophy, and antihypertensive medication use. Linear and logistic regression analyses were performed to examine the association between FSRP and WMH progression, and cognition. RESULTS In all, 207 patients were included, with a mean age of 60±16 y and 54.6% female. FSRP scores risk distribution was: 31.9% scored 0 to 1, 36.7% scored 2 to 3, and 31.4% scored ≥4. The baseline WMH volume was 9.6 cm 3 (IQR: 3.3-28.4 cm 3 ), and the annual rate of WMH progression was 0.9 cm3/year (IQR: 0.1 to 3.1 cm 3 /year). A higher FSRP score was associated with fast WMH progression (odds ratio, 1.45; 95% CI: 1.22-1.72; P<0.001) and a lower MMSE score (23.6 vs. 27.1; P<0.001). There was a dose-dependent relationship between higher FSRP score and fast WMH progression (odds ratios, 2.20, 4.64, 7.86, 8.03 for FSRP scores 1, 2, 3, and ≥4, respectively; trend P <0.001). CONCLUSIONS This study demonstrated an association between higher FSRP scores and accelerated WMH progression, as well as lower cognition.
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Affiliation(s)
| | - Mutlu Demirer
- Department of Radiology, Mayo Clinic, Jacksonville, FL
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2
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Hannan J, Busby N, Roth R, Wilmskoetter J, Newman-Norlund R, Rorden C, Bonilha L, Fridriksson J. Under pressure: the interplay of hypertension and white matter hyperintensities with cognition in chronic stroke aphasia. Brain Commun 2024; 6:fcae200. [PMID: 38894950 PMCID: PMC11184349 DOI: 10.1093/braincomms/fcae200] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2023] [Revised: 05/08/2024] [Accepted: 06/07/2024] [Indexed: 06/21/2024] Open
Abstract
While converging research suggests that increased white matter hyperintensity load is associated with poorer cognition, and the presence of hypertension is associated with increased white matter hyperintensity load, the relationship among hypertension, cognition and white matter hyperintensities is not well understood. We sought to determine the effect of white matter hyperintensity burden on the relationship between hypertension and cognition in individuals with post-stroke aphasia, with the hypothesis that white matter hyperintensity load moderates the relationship between history of hypertension and cognitive function. Health history, Fazekas scores for white matter hyperintensities and Wechsler Adult Intelligence Scale Matrix Reasoning subtest scores for 79 people with aphasia collected as part of the Predicting Outcomes of Language Rehabilitation study at the Center for the Study of Aphasia Recovery at the University of South Carolina and the Medical University of South Carolina were analysed retrospectively. We found that participants with a history of hypertension had increased deep white matter hyperintensity severity (P < 0.001), but not periventricular white matter hyperintensity severity (P = 0.116). Moderation analysis revealed that deep white matter hyperintensity load moderates the relationship between high blood pressure and Wechsler Adult Intelligence Scale scores when controlling for age, education, aphasia severity and lesion volume. The interaction is significant, showing that a history of high blood pressure and severe deep white matter hyperintensities together are associated with poorer Matrix Reasoning scores. The overall model explains 41.85% of the overall variation in Matrix Reasoning score in this group of participants. These findings underscore the importance of considering cardiovascular risk factors in aphasia treatment, specifically hypertension and its relationship to brain health in post-stroke cognitive function.
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Affiliation(s)
- Jade Hannan
- Department of Communication Sciences and Disorders, University of South Carolina, Columbia, SC 29208, USA
| | - Natalie Busby
- Department of Communication Sciences and Disorders, University of South Carolina, Columbia, SC 29208, USA
| | - Rebecca Roth
- Department of Neurology, Emory University, Atlanta, GA 30322, USA
| | - Janina Wilmskoetter
- Department of Health and Rehabilitation Sciences, Medical University of South Carolina, Charleston, SC 29425, USA
| | | | - Chris Rorden
- Department of Psychology, University of South Carolina, Columbia, SC 29208, USA
| | - Leonardo Bonilha
- Department of Pharmacology, Physiology, and Neuroscience, University of South Carolina School of Medicine, Columbia, SC 29209, USA
| | - Julius Fridriksson
- Department of Communication Sciences and Disorders, University of South Carolina, Columbia, SC 29208, USA
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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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4
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Nabizadeh F, Zafari R, Mohamadi M, Maleki T, Fallahi MS, Rafiei N. MRI features and disability in multiple sclerosis: A systematic review and meta-analysis. J Neuroradiol 2024; 51:24-37. [PMID: 38172026 DOI: 10.1016/j.neurad.2023.11.007] [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: 08/20/2023] [Revised: 11/28/2023] [Accepted: 11/28/2023] [Indexed: 01/05/2024]
Abstract
BACKGROUND In this systematic review and meta-analysis, we aimed to investigate the correlation between disability in patients with Multiple sclerosis (MS) measured by the Expanded Disability Status Scale (EDSS) and brain Magnetic Resonance Imaging (MRI) features to provide reliable results on which characteristics in the MRI can predict disability and prognosis of the disease. METHODS A systematic literature search was performed using three databases including PubMed, Scopus, and Web of Science. The selected peer-reviewed studies must report a correlation between EDSS scores and MRI features. The correlation coefficients of included studies were converted to the Fisher's z scale, and the results were pooled. RESULTS Overall, 105 studies A total of 16,613 patients with MS entered our study. We found no significant correlation between total brain volume and EDSS assessment (95 % CI: -0.37 to 0.08; z-score: -0.15). We examined the potential correlation between the volume of T1 and T2 lesions and the level of disability. A positive significant correlation was found (95 % CI: 0.19 to 0.43; z-score: 0.31), (95 % CI: 0.17 to 0.33; z-score: 0.25). We observed a significant correlation between white matter volume and EDSS score in patients with MS (95 % CI: -0.37 to -0.03; z-score: -0.21). Moreover, there was a significant negative correlation between gray matter volume and disability (95 % CI: -0.025 to -0.07; z-score: -0.16). CONCLUSION In conclusion, this systematic review and meta-analysis revealed that disability in patients with MS is linked to extensive changes in different brain regions, encompassing gray and white matter, as well as T1 and T2 weighted MRI lesions.
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Affiliation(s)
- Fardin Nabizadeh
- School of Medicine, Iran University of Medical Sciences, Tehran, Iran.
| | - Rasa Zafari
- School of Medicine, Tehran University of Medical Sciences, Tehran, Iran
| | - Mobin Mohamadi
- School of Medicine, Iran University of Medical Sciences, Tehran, Iran
| | - Tahereh Maleki
- School of Medicine, Tehran University of Medical Sciences, Tehran, Iran
| | | | - Nazanin Rafiei
- School of Medicine, Isfahan University of Medical Sciences, Isfahan, Iran
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5
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Sin MK, Cheng Y, Roseman JM, Zamrini E, Ahmed A. Relationships between Late-Life Blood Pressure and Cerebral Microinfarcts in Octogenarians: An Observational Autopsy Study. J Clin Med 2023; 12:6080. [PMID: 37763020 PMCID: PMC10531732 DOI: 10.3390/jcm12186080] [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: 08/11/2023] [Revised: 09/15/2023] [Accepted: 09/18/2023] [Indexed: 09/29/2023] Open
Abstract
Mid-life high blood pressure (BP) is a risk factor for cerebral microinfarcts. Less is known about the relationship between late-life BP and cerebral microinfarcts, the examination of which is the objective of the current study. This case-control study analyzed data from 551 participants (94.6% aged ≥80 years; 58.6% women) in the Adult Changes in Thought (ACT) study who had autopsy data on microinfarcts and four values of systolic and diastolic blood pressure (SBP and DBP) before death. Using the average of four values, SBP was categorized using 10 mmHg intervals; a trend was defined as a ≥10 mmHg rise or fall from the first to fourth values (average gap of 6.5 years). Multivariable-adjusted regression models were used to examine the associations of BP and microinfarcts, adjusting for age, sex, last BP-to-death time, APOE genotype, and antihypertensive medication use. Microinfarcts were present in 274 (49.7%) participants; there were multiple in 51.8% of the participants, and they were located in cortical areas in 40.5%, subcortical areas in 29.6%, and both areas in 29.9% of the participants. All SBP categories (reference of 100-119 mmHg) and both SBP trends were associated with higher odds of both the presence and number of microinfarcts. The magnitude of these associations was numerically greater for subcortical than cortical microinfarcts. Similar associations were observed with DBP. These hypothesis-generating findings provide new information about the overall relationship between BP and cerebral microinfarcts in octogenarians.
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Affiliation(s)
- Mo-Kyung Sin
- College of Nursing, Seattle University, Seattle, WA 98122, USA
| | - Yan Cheng
- Biomedical Informatics Center and School of Medicine & Health Sciences, George Washington University, Washington, DC 20052, USA; (Y.C.); (A.A.)
| | - Jeffrey M. Roseman
- Department of Epidemiology, University of Alabama at Birmingham, Birmingham, AL 35233, USA;
| | - Edward Zamrini
- Biomedical Informatics Center and School of Medicine & Health Sciences, George Washington University, Washington, DC 20052, USA; (Y.C.); (A.A.)
- Irvine Clinical Research, Irvine, CA 92614, USA
- VA Medical Center, Washington, DC 20242, USA
| | - Ali Ahmed
- Biomedical Informatics Center and School of Medicine & Health Sciences, George Washington University, Washington, DC 20052, USA; (Y.C.); (A.A.)
- VA Medical Center, Washington, DC 20242, USA
- School of Medicine, Georgetown University, Washington, DC 20057, USA
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Winkler J, Piedade GS, Rubbert C, Hofmann BB, Kamp MA, Slotty PJ. Cerebral perfusion changes in acute subdural hematoma. Acta Neurochir (Wien) 2023; 165:2381-2387. [PMID: 37460666 PMCID: PMC10477107 DOI: 10.1007/s00701-023-05703-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2023] [Accepted: 06/25/2023] [Indexed: 09/05/2023]
Abstract
INTRODUCTION Acute subdural hematoma (aSDH) is one of the main causes of high mortality and morbidity in traumatic brain injury. Prognosis is poor due to the rapid volume shift and mass effect. Cerebral perfusion is likely affected in this condition. This study quantifies perfusion changes in aSDH using early ER polytrauma CT with perfusion imaging (CTP). METHODS Data of 54 patients with traumatic aSDH were retrospectively collected. Glasgow Coma scale (GCS), perfusion parameters, therapeutic decisions and imaging data including hematoma thickness, midline shift, and hematoma localization were analyzed. The cortical perfusion parameters of each hemisphere, the area anterior to the hematoma (AAH), area below the hematoma (ABH), area posterior to the hematoma (PAH), and corresponding mirrored contralateral regions were determined. RESULTS We found a significant difference in Tmax in affected and unaffected whole-hemisphere data (mean 4.0 s vs. 3.3 s, p < 0.05) and a significantly different mean for Tmax in ABH and for the corresponding mirrored area (mABH) (mean 3.8 s vs. 3.1 s, p < 0.05). No significant perfusion changes in cerebral blood flow (CBF), cerebral blood volume (CBV), and mean transit time (MTT) were found. CONCLUSION There was a significant elevation of time to maximum (Tmax) values in the underlying cortical area of aSDH. Possible pathophysiological explanations, the influence on immediate surgical decision-making and further therapeutic consequences have to be evaluated.
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Affiliation(s)
- J Winkler
- Department of Neurosurgery, Heinrich-Heine-University, Düsseldorf, Germany
| | - G S Piedade
- Department of Neurosurgery, Heinrich-Heine-University, Düsseldorf, Germany.
- Department of Pediatric Neurosurgery, Nicklaus Children's Hospital, University of Miami, 3100 SW 62nd Ave, Miami, FL, 33155, USA.
| | - C Rubbert
- Department of Diagnostic and Interventional Radiology, Heinrich-Heine-University, Düsseldorf, Germany
| | - B B Hofmann
- Department of Neurosurgery, Heinrich-Heine-University, Düsseldorf, Germany
| | - M A Kamp
- Department of Neurosurgery, Friedrich-Schiller-University Jena, Jena, Germany
| | - P J Slotty
- Department of Neurosurgery, Heinrich-Heine-University, Düsseldorf, Germany
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7
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Herman AL, de Havenon A, Falcone GJ, Prabhakaran S, Sheth KN. Racial/Ethnic Variation in White Matter Hyperintensity Progression in the ACCORDION MIND Study. Neurologist 2023; 28:157-159. [PMID: 35834785 DOI: 10.1097/nrl.0000000000000454] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
BACKGROUND White matter hyperintensities (WMHs) are linked to cognitive decline and stroke. We investigate the impact of race on WMH progression in the Action to Control Cardiovascular Risk in Diabetes Memory in Diabetes (ACCORDION MIND) trial. MATERIALS AND METHODS The primary outcome is WMH progression in milliliters, evaluated by fitting linear regression to WMH volume on the month 80 magnetic resonance imaging (MRI) and including the WMH volume on the baseline MRI. The primary predictor is patient race, with the exclusion of patients defined as "other" race. We also derived predicted probabilities of our outcome for systolic blood pressure (SBP) levels. RESULTS We included 276 patients who completed the baseline and month 80 MRI, of which 207 (75%) were White, 48 (17%) Black, and 21 (8%) Hispanic. During follow-up, the mean number of SBP, low-density lipoprotein (LDL), and A1c measurements per patient was 21, 8, and 15. The median (IQR) WMH progression was 1.5 mL (0.5 to 3.9) for Black patients, 1.0 mL (0.4 to 4.0) for Hispanics, and 1.3 mL (0.5 to 2.7) for Whites (Kruskal-Wallis test, P =0.59). In the multivariate regression model, Black, compared with White, patients had significantly more WMH progression (β Coefficient 1.26, 95% confidence interval 0.45 to 2.06, P =0.002). Hispanic, compared with White, patients neither have significantly different WMH progression ( P =0.392), nor was there a difference when comparing Hispanic to Black patients ( P =0.162). The predicted WMH progression was significantly higher for Black compared with White patients across a mean SBP of 117 to 139 mm Hg. CONCLUSIONS Black diabetic patients in Action to Control Cardiovascular Risk in Diabetes Memory in Diabetes (ACCORDION MIND) have a higher risk of WMH progression than White patients across a normal range of SBP.
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Affiliation(s)
- Alison L Herman
- Department of Neurology, Yale University School of Medicine, New Haven, CT
| | - Adam de Havenon
- Department of Neurology, Yale University School of Medicine, New Haven, CT
| | - Guido J Falcone
- Department of Neurology, Yale University School of Medicine, New Haven, CT
| | | | - Kevin N Sheth
- Department of Neurology, Yale University School of Medicine, New Haven, CT
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Wang L, Lin H, Zhao Z, Chen L, Wu L, Liu T, Li J, Huang CC, Peng Y, Lo CYZ, Gao X. Sex disparity of cerebral white matter hyperintensity in the hypertensive elderly: The Shanghai Changfeng study. Hum Brain Mapp 2023; 44:2099-2108. [PMID: 36583389 PMCID: PMC9980881 DOI: 10.1002/hbm.26196] [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] [Received: 04/22/2022] [Revised: 12/04/2022] [Accepted: 12/18/2022] [Indexed: 12/31/2022] Open
Abstract
White matter hyperintensity (WMH) is associated with vascular hemodynamic alterations and reflects white matter injury. To date, the sex difference of tract-specific WMH and the relationship between high blood pressure (BP) and tract-specific WMH remain unclear. We recruited 515 subjects from the Shanghai Changfeng study (range 53-89 years, mean age 67.33 years). Systolic and diastolic blood pressure (SBP and DBP) were collected and used to calculate pulse pressure (PP). Magnetic resonance T1 and T2 FLAIR images were acquired to measure WMH and calculate WMH index. The ANCOVA test was performed to test the difference between sexes, and the linear regression model was used to examine the associations between BP and WMH index. Men showed higher WMH index than women in all white matter tracts (p < .001, respectively) except for the bilateral superior longitudinal fasciculus (SLF) and its left temporal part (tSLF). High SBP and PP was associated with a lower WMH index on the left corticospinal tract (CST), SLF, tSLF and right cingulum in hippocampus (p ≤ .001, respectively) in women, while high DBP was associated with a higher WMH index on the bilateral CST (left p < .001; right p = .001), left inferior longitudinal fasciculus (p < .001) and inferior fronto-occipital fasciculus (p = .002) in men. Men tend to have more WMH compared to women. A high SBP/PP relates to a lower WMH burden in women. This suggests that women could benefit from higher blood pressure in older age.
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Affiliation(s)
- Liangqi Wang
- Department of Radiology, Putuo Hospital, Shanghai University of Traditional Chinese Medicine, Shanghai, China.,Department of Endocrinology and Metabolism, Zhongshan Hospital, Fudan University, Shanghai, China.,Human Phenome Institute, Fudan University, Shanghai, China.,School of Life Sciences, Fudan University, Shanghai, China
| | - Huandong Lin
- Department of Endocrinology and Metabolism, Zhongshan Hospital, Fudan University, Shanghai, China.,Human Phenome Institute, Fudan University, Shanghai, China.,Institute for Metabolic Diseases, Fudan University, Shanghai, China
| | - Zehua Zhao
- Department of Radiology, Putuo Hospital, Shanghai University of Traditional Chinese Medicine, Shanghai, China
| | - Lingyan Chen
- Department of Geriatrics, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Li Wu
- Department of Endocrinology and Metabolism, Zhongshan Hospital, Fudan University, Shanghai, China.,Institute for Metabolic Diseases, Fudan University, Shanghai, China
| | - Ting Liu
- Department of Endocrinology and Metabolism, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Jing Li
- Department of Endocrinology and Metabolism, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Chu-Chung Huang
- School of Psychology and Cognitive Science, Institute of Cognitive Neuroscience, East China Normal University, Shanghai, China
| | - Yifeng Peng
- Department of Radiology, Putuo Hospital, Shanghai University of Traditional Chinese Medicine, Shanghai, China
| | - Chun-Yi Zac Lo
- Institute of Science and Technology for Brain Inspired Intelligence, Fudan University, Shanghai, China
| | - Xin Gao
- Department of Endocrinology and Metabolism, Zhongshan Hospital, Fudan University, Shanghai, China.,Human Phenome Institute, Fudan University, Shanghai, China.,Institute for Metabolic Diseases, Fudan University, Shanghai, China
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Li Z, Wang W, Sang F, Zhang Z, Li X. White matter changes underlie hypertension-related cognitive decline in older adults. Neuroimage Clin 2023; 38:103389. [PMID: 37004321 PMCID: PMC10102561 DOI: 10.1016/j.nicl.2023.103389] [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: 02/03/2023] [Revised: 03/18/2023] [Accepted: 03/25/2023] [Indexed: 03/31/2023]
Abstract
Hypertension has been well recognized as a risk factor for cognitive impairment and dementia. Although the underlying mechanisms of hypertension-affected cognitive deterioration are not fully understood, white matter changes (WMCs) seem to play an important role. WMCs include low microstructural integrity and subsequent white matter macrostructural lesions, which are common on brain imaging in hypertensive patients and are critical for multiple cognitive domains. This article provides an overview of the impact of hypertension on white matter microstructural and macrostructural changes and its link to cognitive dysfunction. Hypertension may induce microstructural changes in white matter, especially for the long-range fibers such as anterior thalamic radiation (ATR) and inferior fronto-occipital fasciculus (IFOF), and then macrostructural abnormalities affecting different lobes, especially the periventricular area. Different regions' WMCs would further exert different effects to specific cognitive domains and accelerate brain aging. As a modifiable risk factor, hypertension might provide a new perspective for alleviating and delaying cognitive impairment.
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Affiliation(s)
- Zilin Li
- State Key Laboratory of Cognitive Neuroscience and Learning, Beijing Normal University, Beijing 100875, China; Beijing Aging Brain Rejuvenation Initiative Centre, Beijing Normal University, Beijing 100875, China
| | - Wenxiao Wang
- State Key Laboratory of Cognitive Neuroscience and Learning, Beijing Normal University, Beijing 100875, China; Beijing Aging Brain Rejuvenation Initiative Centre, Beijing Normal University, Beijing 100875, China
| | - Feng Sang
- State Key Laboratory of Cognitive Neuroscience and Learning, Beijing Normal University, Beijing 100875, China; Beijing Aging Brain Rejuvenation Initiative Centre, Beijing Normal University, Beijing 100875, China
| | - Zhanjun Zhang
- State Key Laboratory of Cognitive Neuroscience and Learning, Beijing Normal University, Beijing 100875, China; Beijing Aging Brain Rejuvenation Initiative Centre, Beijing Normal University, Beijing 100875, China
| | - Xin Li
- State Key Laboratory of Cognitive Neuroscience and Learning, Beijing Normal University, Beijing 100875, China; Beijing Aging Brain Rejuvenation Initiative Centre, Beijing Normal University, Beijing 100875, China.
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10
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High-Density Lipoprotein Is Associated with Leukoaraiosis Severity in Patients with Acute Ischemic Stroke. Neurotox Res 2022; 40:900-908. [PMID: 35386025 DOI: 10.1007/s12640-022-00502-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2021] [Revised: 03/28/2022] [Accepted: 03/29/2022] [Indexed: 10/18/2022]
Abstract
Many patients with acute ischemic stroke (AIS) are found to accompany with leukoaraiosis (LA) in brain imaging. The risk factors of LA in patients with AIS were examined in this study. Patients with AIS were recruited and underwent head magnetic resonance imaging. According to Fazekas scores, patients were divided into LA group and non-LA group. We compared demographic and laboratory characteristics in two groups. Multivariate logistic regression analysis demonstrated that high-density lipoprotein (HDL), age, stroke history, admission SBP, and homocysteine were independent risk factors for LA in patients with AIS (P < 0.05). Multinomial logistic regression analysis demonstrated that HDL was an independent risk factor for moderate LA (OR 4.151, 95% CI 1.898-9.078, P < 0.001) and severe LA (OR 3.151, 95% CI 1.350-7.358, P = 0.008). In order to further explore the correlation between HDL level and the severity of LA, HDL was categorized in quartiles and multinomial logistic regression analysis was presented. Regression analysis showed that HDL ≥ 1.34 mmol/L was correlated with moderate and severe LA after adjusting for corresponding confounding factors in different models. After 1-year follow-up, patients were divided into regular statin therapy group and irregular statin therapy group. There was no significant difference in HDL level between two groups; however, the proportion of patients with increased Fazekas scores in regular statin therapy group was significantly less than that in the irregular statin therapy group (P < 0.05). In conclusion, HDL was an independent risk factor for LA and associated with the severity of LA in patients with AIS; regular statin therapy may be negatively related with the progress of LA. These results provide more evidences for controlling risk factors and severity of LA in patient with AIS.
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11
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Five years of exercise intervention at different intensities and development of white matter hyperintensities in community dwelling older adults, a Generation 100 sub-study. Aging (Albany NY) 2022; 14:596-622. [PMID: 35042832 PMCID: PMC8833118 DOI: 10.18632/aging.203843] [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] [Received: 11/19/2021] [Accepted: 01/04/2022] [Indexed: 11/30/2022]
Abstract
We investigated if a five-year supervised exercise intervention with moderate-intensity continuous training (MICT) or high-intensity interval training (HIIT) versus control; physical activity according to national guidelines, attenuated the growth of white matter hyperintensities (WMH). We hypothesized that supervised exercise, in particular HIIT, reduced WMH growth. Older adults from the general population participating in the RCT Generation 100 Study were scanned at 3T MRI at baseline (age 70–77), and after 1-, 3- and 5-years. At each follow-up, cardiorespiratory fitness was measured with ergospirometry, and physical activity plus clinical data collected. Manually delineated total WMH, periventricular (PWMH), deep (DWMH), and automated total white matter hypointensity volumes were obtained. No group by time interactions were present in linear mixed model analyses with the different WMH measurements as outcomes. In the combined exercise (MICT&HIIT) group, a significant group by time interaction was uncovered for PWMH volume, with a larger increase in the MICT&HIIT group. Cardiorespiratory fitness at the follow-ups or change in cardiorespiratory fitness over time were not associated with any WMH measure. Contrary to our hypothesis, taking part in MICT or HIIT over a five-year period did not attenuate WMH growth compared to being in a control group following national physical activity guidelines.
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12
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Tang X, Jiang L, Luo Y, Fan H, Song L, Liu P, Chen Y. Leukoaraiosis and acute ischemic stroke. Eur J Neurosci 2021; 54:6202-6213. [PMID: 34331366 DOI: 10.1111/ejn.15406] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2020] [Revised: 07/26/2021] [Accepted: 07/26/2021] [Indexed: 11/30/2022]
Abstract
Ischaemic stroke is characterized by high morbidity, high disability rate, high mortality and high recurrence rate, which can have a grave impact on the quality of life of the patients and consequently becomes an economic burden on their families and society. With the developments in imaging technology in recent years, patients with acute cerebral infarction are predominantly more likely to be diagnosed with leukoaraiosis (LA). LA is a common degenerative disease of the nervous system, which is related to cognitive decline, depression, abnormal gait, ischaemic stroke and atherosclerosis. The aetiology of LA is not clear and there is no gold standard for imaging assessment. Related studies have shown that LA has an adverse effect on the prognosis of cerebral infarction, but some experts have contrary beliefs. Hence, we undertook the present review of the literature on the mechanism and the effect of LA on the prognosis of patients with acute ischaemic stroke.
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Affiliation(s)
- Xiaojia Tang
- Department of Rehabilitation Medicine, Northern Jiangsu People's Hospital Affiliated to Yangzhou University, Yangzhou City, China
| | - Li Jiang
- Department of Neurology, Clinical Medical College, Yangzhou University, Yangzhou City, China
| | - Yuhan Luo
- Health Management Center, People's Hospital of Deyang City, Deyang City, China
| | - Hongyang Fan
- Department of Neurology, Xuzhou Medical University Affiliated Hospital of Lianyungang, Lianyungang City, China
| | - Lilong Song
- Department of Neurology, Shanghai Fourth People's Hospital, Shanghai City, China
| | - Peipei Liu
- Department of Neurology, Clinical Medical College, Yangzhou University, Yangzhou City, China
| | - Yingzhu Chen
- Department of Neurology, Clinical Medical College, Yangzhou University, Yangzhou City, China
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Paradela RS, Ferreira NV, Nucci MP, Cabella B, Martino LM, Torres LA, Costa DID, Consolim-Colombo FM, Suemoto CK, Irigoyen MC. Relation of a Socioeconomic Index with Cognitive Function and Neuroimaging in Hypertensive Individuals. J Alzheimers Dis 2021; 82:815-826. [PMID: 34092639 DOI: 10.3233/jad-210143] [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] [Indexed: 12/27/2022]
Abstract
BACKGROUND Socioeconomic factors are important contributors to brain health. However, data from developing countries (where social inequalities are the most prominent) are still scarce, particularly about hypertensive individuals. OBJECTIVE To evaluate the relationship between socioeconomic index, cognitive function, and cortical brain volume, as well as determine whether white matter hyperintensities are mediators of the association of the socioeconomic index with cognitive function in hypertensive individuals. METHODS We assessed 92 hypertensive participants (mean age = 58±8.6 years, 65.2%female). Cognitive evaluation and neuroimaging were performed and clinical and sociodemographic data were collected using questionnaires. A socioeconomic index was created using education, income, occupation (manual or non-manual work), and race. The associations of the socioeconomic index with cognitive performance and brain volume were investigated using linear regression models adjusted for age, sex, time of hypertension since diagnosis, and comorbidities. A causal mediation analysis was also conducted. RESULTS Better socioeconomic status was associated with better visuospatial ability, executive function, and global cognition. We found associations between a better socioeconomic index and a higher parietal lobe volume. White matter hyperintensities were also not mediators in the relationship between the socioeconomic index and cognitive performance. CONCLUSION Socioeconomic disadvantages are associated with worse cognitive performance and brain volume in individuals with hypertension.
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Affiliation(s)
- Regina Silva Paradela
- Instituto do Coracao (InCor), Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de São Paulo, São Paulo, SP, Brazil
| | - Naomi Vidal Ferreira
- Departamento de Clínica Médica, Faculdade de Medicina, Universidade de São Paulo, São Paulo, SP, Brazil.,Adventist University of São Paulo, Engenheiro Coelho, SP, Brazil
| | - Mariana Penteado Nucci
- Laboratory of Medical Investigations on Magnetic Resonance Imaging (LIM-44), Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de São Paulo, São Paulo, SP, Brazil
| | - Brenno Cabella
- Institute of Theoretical Physics, São Paulo State University (IFT-UNESP), São Paulo, SP, Brazil
| | - Luiza Menoni Martino
- Instituto do Coracao (InCor), Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de São Paulo, São Paulo, SP, Brazil
| | - Laura Aló Torres
- Instituto do Coracao (InCor), Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de São Paulo, São Paulo, SP, Brazil
| | - Danielle Irigoyen da Costa
- Brain Institute (InsCer), Pontifícia Universidade Católica do Rio Grande do Sul (PUCRS), Porto Alegre, RS, Brazil
| | | | - Claudia Kimie Suemoto
- Division of Geriatrics, Faculdade de Medicina, Universidade de São Paulo, São Paulo, SP, Brazil
| | - Maria Claudia Irigoyen
- Instituto do Coracao (InCor), Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de São Paulo, São Paulo, SP, Brazil
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Development of a protocol to assess within-subject, regional white matter hyperintensity changes in aging and dementia. J Neurosci Methods 2021; 360:109270. [PMID: 34171312 DOI: 10.1016/j.jneumeth.2021.109270] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/01/2021] [Revised: 06/14/2021] [Accepted: 06/18/2021] [Indexed: 11/24/2022]
Abstract
BACKGROUND White matter hyperintensities (WMH), associated with both dementia risk and progression, can individually progress, remain stable, or even regress influencing cognitive decline related to specific cerebrovascular-risks. This study details the development and validation of a registration protocol to assess regional, within-subject, longitudinal WMH changes (ΔWMH) that is currently lacking in the field. NEW METHOD 3D-FLAIR images (baseline and one-year-visit) were used for protocol development and validation. The method was validated by assessing the correlation between forward and reverse longitudinal registration, and between summated regional progression-regression volumes and Global ΔWMH. The clinical relevance of growth-regression ΔWMH were explored in relation to an executive function test. RESULTS MRI scans for 79 participants (73.5 ± 8.8 years) were used in this study. Global ΔWMH vs. summated regional progression-regression volumes were highly associated (r2 = 0.90; p-value < 0.001). Bi-directional registration validated the registration method (r2 = 0.999; p-value < 0.001). Growth and regression, but not overall ΔWMH, were associated with one-year declines in performance on Trial-Making-Test-B. COMPARISON WITH EXISTING METHOD(S) This method presents a unique registration protocol for maximum tissue alignment, demonstrating three distinct patterns of longitudinal within-subject ΔWMH (stable, growth and regression). CONCLUSIONS These data detail the development and validation of a registration protocol for use in assessing within-subject, voxel-level alterations in WMH volume. The methods developed for registration and intensity correction of longitudinal within-subject FLAIR images allow regional and within-lesion characterization of longitudinal ΔWMH. Assessing the impact of associated cerebrovascular-risks and longitudinal clinical changes in relation to dynamic regional ΔWMH is needed in future studies.
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Valdés Hernández MDC, Grimsley-Moore T, Sakka E, Thrippleton MJ, Chappell FM, Armitage PA, Makin S, Wardlaw JM. Lacunar Stroke Lesion Extent and Location and White Matter Hyperintensities Evolution 1 Year Post-lacunar Stroke. Front Neurol 2021; 12:640498. [PMID: 33746892 PMCID: PMC7976454 DOI: 10.3389/fneur.2021.640498] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2020] [Accepted: 02/08/2021] [Indexed: 11/13/2022] Open
Abstract
Lacunar strokes are a common type of ischemic stroke. They are associated with long-term disability, but the factors affecting the dynamic of the infarcted lesion and the brain imaging features associated with them, reflective of small vessel disease (SVD) severity, are still largely unknown. We investigated whether the distribution, volume and 1-year evolution of white matter hyperintensities (WMH), one of these SVD features, relate to the extent and location of these infarcts, accounting for vascular risk factors. We used imaging and clinical data from all patients [n = 118, mean age 64.9 (SD 11.75) years old] who presented to a regional hospital with a lacunar stroke syndrome within the years 2010 and 2013 and consented to participate in a study of stroke mechanisms. All patients had a brain MRI scan at presentation, and 88 had another scan 12 months after. Acute lesions (i.e., recent small subcortical infarcts, RSSI) were identified in 79 patients and lacunes in 77. Number of lacunes was associated with baseline WMH volume (B = 0.370, SE = 0.0939, P = 0.000174). RSSI volume was not associated with baseline WMH volume (B = 3.250, SE = 2.117, P = 0.129), but predicted WMH volume change (B = 2.944, SE = 0.913, P = 0.00184). RSSI location was associated with the spatial distribution of WMH and the pattern of 1-year WMH evolution. Patients with the RSSI in the centrum semiovale (n = 33) had significantly higher baseline volumes of WMH, recent and old infarcts, than patients with the RSSI located elsewhere [median 33.69, IQR (14.37 50.87) ml, 0.001 ≤ P ≤ 0.044]. But patients with the RSSI in the internal/external capsule/lentiform nucleus experienced higher increase of WMH volume after a year [n = 21, median (IQR) from 18 (11.70 31.54) ml to 27.41 (15.84 40.45) ml]. Voxel-wise analyses of WMH distribution in patients grouped per RSSI location revealed group differences increased in the presence of vascular risk factors, especially hypertension and recent or current smoking habit. In our sample of patients presenting to the clinic with lacunar strokes, lacunar strokes extent influenced WMH volume fate; and RSSI location and WMH spatial distribution and dynamics were intertwined, with differential patterns emerging in the presence of vascular risk factors. These results, if confirmed in wider samples, open potential avenues in stroke rehabilitation to be explored further.
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Affiliation(s)
| | - Tara Grimsley-Moore
- College of Medicine and Veterinary Medicine, University of Edinburgh, Edinburgh, United Kingdom
| | - Eleni Sakka
- Centre for Clinical Brain Sciences, University of Edinburgh, Edinburgh, United Kingdom
| | | | - Francesca M. Chappell
- Centre for Clinical Brain Sciences, University of Edinburgh, Edinburgh, United Kingdom
| | - Paul A. Armitage
- Academic Unit of Radiology, University of Sheffield, Sheffield, United Kingdom
| | - Stephen Makin
- Centre for Rural Health, University of Aberdeen, Aberdeen, United Kingdom
| | - Joanna M. Wardlaw
- Centre for Clinical Brain Sciences, University of Edinburgh, Edinburgh, United Kingdom
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Frederiksen KS, Cooper C, Frisoni GB, Frölich L, Georges J, Kramberger MG, Nilsson C, Passmore P, Mantoan Ritter L, Religa D, Schmidt R, Stefanova E, Verdelho A, Vandenbulcke M, Winblad B, Waldemar G. A European Academy of Neurology guideline on medical management issues in dementia. Eur J Neurol 2020; 27:1805-1820. [PMID: 32713125 PMCID: PMC7540303 DOI: 10.1111/ene.14412] [Citation(s) in RCA: 44] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2020] [Revised: 06/12/2020] [Accepted: 06/13/2020] [Indexed: 12/17/2022]
Abstract
BACKGROUND AND PURPOSE Dementia is one of the most common disorders and is associated with increased morbidity, mortality and decreased quality of life. The present guideline addresses important medical management issues including systematic medical follow-up, vascular risk factors in dementia, pain in dementia, use of antipsychotics in dementia and epilepsy in dementia. METHODS A systematic review of the literature was carried out. Based on the Grading of Recommendations, Assessment, Development and Evaluations (GRADE) framework, we developed a guideline. Where recommendations based on GRADE were not possible, a good practice statement was formulated. RESULTS Systematic management of vascular risk factors should be performed in patients with mild to moderate dementia as prevention of cerebrovascular pathology may impact on the progression of dementia (Good Practice statement). Individuals with dementia (without previous stroke) and atrial fibrillation should be treated with anticoagulants (weak recommendation). Discontinuation of opioids should be considered in certain individuals with dementia (e.g. for whom there are no signs or symptoms of pain or no clear indication, or suspicion of side effects; Good Practice statement). Behavioral symptoms in persons with dementia should not be treated with mild analgesics (weak recommendation). In all patients with dementia treated with opioids, assessment of the individual risk-benefit ratio should be performed at regular intervals. Regular, preplanned medical follow-up should be offered to all patients with dementia. The setting will depend on the organization of local health services and should, as a minimum, include general practitioners with easy access to dementia specialists (Good Practice statement). Individuals with dementia and agitation and/or aggression should be treated with atypical antipsychotics only after all non-pharmacological measures have been proven to be without benefit or in the case of severe self-harm or harm to others (weak recommendation). Antipsychotics should be discontinued after cessation of behavioral disturbances and in patients in whom there are side effects (Good Practice statement). For treatment of epilepsy in individuals with dementia, newer anticonvulsants should be considered as first-line therapy (Good Practice statement). CONCLUSION This GRADE-based guideline offers recommendations on several important medical issues in patients with dementia, and thus adds important guidance for clinicians. For some issues, very little or no evidence was identified, highlighting the importance of further studies within these areas.
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Affiliation(s)
- K. S. Frederiksen
- Department of NeurologyDanish Dementia Research CenterRigshospitaletUniversity of CopenhagenCopenhagenDenmark
| | - C. Cooper
- Department of Clinical Educational and Health PsychologyUniversity College LondonLondonUK
| | - G. B. Frisoni
- Memory ClinicUniversity Hospital of GenevaUniversity of GenevaGenevaSwitzerland
| | - L. Frölich
- Department of Geriatric PsychiatryZentralinstitut für Seelische Gesundheit MannheimMedical Faculty MannheimUniversity of HeidelbergMannheimGermany
| | | | - M. G. Kramberger
- Department of NeurologyCenter for Cognitive ImpairmentsUniversity Medical Center Ljubljana, and Medical facultyUniversity of LjubljanaLjubljanaSlovenia
| | - C. Nilsson
- Department of Neurology and Rehabilitation MedicineSkåne University HospitalLundSweden
- Clinical Memory Research UnitDepartment of Clinical SciencesLund UniversityMalmöSweden
| | | | - L. Mantoan Ritter
- Epilepsy CentreKing's College NHS Foundation TrustKing´s College LondonLondonUK
| | - D. Religa
- Division of Clinical GeriatricsDepartment of Neurobiology, Care Sciences and SocietyKarolinska InstitutetNeo, StockholmSweden
- Karolinska University HospitalTheme AgingHuddingeSweden
| | - R. Schmidt
- University Clinic for NeurologyMedical University of GrazGrazAustria
| | - E. Stefanova
- Medical FacultyNeurology clinic CCSUniversity of BelgradeBelgradeSerbia
| | - A. Verdelho
- Department of Neurosciences and Mental HealthCHLNorte‐Hospital de Santa MariaIMMISAMBFaculty of MedicineUniversity of LisbonLisbonPortugal
| | - M. Vandenbulcke
- Department of NeurosciencesKU LeuvenGeriatric PsychiatryUniversity Hospitals LeuvenLeuvenBelgium
| | - B. Winblad
- Karolinska University HospitalTheme AgingHuddingeSweden
- Division of NeurogeriatricsDepartment of Neurobiology, Care Sciences and SocietyKarolinska InstitutetBioClinicumSolnaSweden
| | - G. Waldemar
- Department of NeurologyDanish Dementia Research CenterRigshospitaletUniversity of CopenhagenCopenhagenDenmark
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Zhang D, Tang Y, Ge J, Liu Y, Jin J, He M. Age and Diastolic Blood Pressure Play an Important Role in the Progression of White Matter Lesions: A Meta-Analysis. Eur Neurol 2020; 83:351-359. [PMID: 32906133 DOI: 10.1159/000510077] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2020] [Accepted: 07/10/2020] [Indexed: 11/19/2022]
Abstract
INTRODUCTION White matter lesions (WMLs) are currently considered as a cerebral microvascular disease, and hypertension is considered as its most important risk factor. This study analysis systematically evaluated the effects of systolic blood pressure (SBP) and diastolic blood pressure (DBP) on the progression of WMLs. METHODS We searched the MeSH terms: "white matter," "blood pressure," "hypertension," "Leukoencephalopathy," and "leukoaraiosis" on PubMed and Cochrane from January 2000 to August 2019. A total of 12 closely related literature were included for research. RESULTS The results of the meta-analysis showed that the increase of both SBP and DBP can promote the progression of WMLs (respectively, odds ratio [OR] = 2.90, 95% confidence interval [CI] 2.86-2.94; OR = 3.13, 95% CI 3.03-3.23). Subgroup analysis found that patients with hypertension aged younger than 70 years are at a greater risk of WML progression when their DBP increased (OR = 4.69, 95% CI 3.31-6.65). CONCLUSION The relationship between DBP and WMLs is closer than that of SBP. Also, the risk of WML progression in patients aged under 70 years was higher than that in patients aged over 70 years. Furthermore, when DBP is elevated in patients younger than 70 years of age, the risk of WML progression may be higher. Therefore, it is expected that more researchers will attach importance to the change in DBP and identify the range of blood pressure and strategies that control DBP, thus contributing to delay the progression of WMLs.
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Affiliation(s)
- Dong Zhang
- Department of Neurology, The affiliated Lianyungang Hospital of Xuzhou Medical University, Lianyungang, China
| | - Yi Tang
- Department of Neurology, The affiliated Lianyungang Hospital of Xuzhou Medical University, Lianyungang, China
| | - Jian Ge
- Department of Neurology, The affiliated Lianyungang Hospital of Xuzhou Medical University, Lianyungang, China
| | - Yumeng Liu
- Department of Neurology, The affiliated Lianyungang Hospital of Xuzhou Medical University, Lianyungang, China
| | - Jing Jin
- Department of Neurology, The affiliated Lianyungang Hospital of Xuzhou Medical University, Lianyungang, China
| | - Mingli He
- Department of Neurology, The affiliated Lianyungang Hospital of Xuzhou Medical University, Lianyungang, China,
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