A door-to-door survey of intracranial atherosclerosis in Liangbei County, China

MetS in the prediction of asymptomatic intracranial arterial stenosis: the potential mediating role of hsCRP

BACKGROUND

We aimed to investigate the relationships between metabolic syndrome (MetS) and its severity score (Metsss) with asymptomatic intracranial arterial stenosis (aICAS) while also assessing the additional effect of high-sensitivity C reactive protein (hsCRP).

METHODS

This cross-sectional study included 2390 individuals who underwent health examinations at our centre from June 2019 to August 2023. Participants received physical examinations, laboratory tests and magnetic resonance angiography evaluations. MetS was defined by the modified acknowledged criteria and quantified by Metsss. Logistic regression, interaction analysis and mediation analysis were employed.

RESULTS

Among the 2390 participants, 135 (5.65%) had aICAS, and 726 (30.40%) had MetS. After adjusting for confounders, MetS was significantly associated with aICAS (OR: 1.68, 95% CI: 1.16 to 2.43, p=0.006). The prevalence of aICAS increased significantly from 3.6% to 8.6% as the number of MetS components increased. Higher quartiles of Metsss also significantly increased aICAS risk (P for trend <0.001). After multivariable adjustment, MetS (p=0.001) and elevated Metsss (p<0.001) were only associated with posterior circulation aICAS (vs anterior). Furthermore, participants with both MetS and elevated hsCRP levels had a greater risk for aICAS (OR: 2.32, 95% CI: 1.36 to 3.96, p=0.002). hsCRP mediated the association between MetS and alCAS in participants ≤65 years old.

CONCLUSIONS

MetS and Metsss were independently associated with the risk of aICAS. The mediating effect of hsCRP on the relationship between MetS and aICAS appears to be age-dependent. These findings offer valuable insights into clinical decision making of aICAS and further improve the primary stroke prevention.

A Long-Term Outcome of Symptomatic Middle Cerebral Artery Undergoing Intracranial Angioplasty or Stenting

OBJECTIVE

For symptomatic stenosis in the middle cerebral artery (MCA), intracranial angioplasty and stenting are frequently employed. However, limited data exist regarding their long-term impact. Our study demonstrates the long-term advantages in preventing ischemic events through a 5-year follow-up period.

METHODS

A set of 41 individuals with symptomatic stenosis in the MCA who underwent angioplasty or stenting procedures between October 2004 and April 2018 at various hospitals in Southwest China were prospectively enrolled in the study. The rates of successful revascularization, complications, imaging observations, and clinical outcomes were systematically assessed.

RESULTS

A total of 41 individuals successfully underwent stenting, respectively. After stenting, the extent of stenosis was decreased from 71.8% (56-87.8%) to 24.9% (0-45%). The mean follow-up period is 36.9 ± 13.68 months (range, 11-67 months). There was no deterioration of neurological function or a new ischemic event. A DSA or CT angiography was conducted after the procedure and demonstrated no in-stent restenosis. No patient experienced restenosis below 50% during the mean follow-up period. The morbidity and mortality rates of the case series were 7.3% and 2.4%, respectively.

CONCLUSIONS

In the treatment of symptomatic MCA atherosclerotic stenoses, intracranial angioplasty and stenting are demonstrated to be technically feasible and safe. Its early and long-term efficacy on ischemic event prevention is acceptable, with a reduced level of restenosis, although the representative sample is tiny.

A clinical and computed tomography-based nomogram to predict the outcome in patients with anterior circulation large vessel occlusion after endovascular mechanical thrombectomy

PURPOSE

To explore the positive predictors of the clinical outcome in acute ischemic stroke (AIS) patients with anterior circulation large vessel occlusion (ACLVO) after endovascular mechanical thrombectomy (EMT) at a 90-day follow-up, and to establish a nomogram model to predict the clinical outcome.

MATERIALS AND METHODS

AIS patients with ACLVO detected by multimodal Computed Tomography imaging who underwent EMT were collected. Patients were divided into the favorable and the unfavorable groups according to the 90-day modified Rankin Scale (mRS) score. Univariate and multivariate analyses were performed to investigate predictors of the favorable outcome (mRS of 0-2). A nomogram model for predicting the clinical outcome after EMT was drawn, and the receiver operating characteristic (ROC) curve was used to evaluate its predictive value.

RESULTS

Totally 105 patients including 65 patients in the favorable group and 40 in the unfavorable group were enrolled. Multivariate logistic regression analysis showed that admission National Institute of Health Stroke scale (NIHSS) score [0.858 (95% CI 0.778-0.947)], ACLVO at M2 [20.023 (95% CI 2.204-181.907)] and infarct core (IC) volume [0.943 (95% CI 0.917-0.969)] was positively correlated with favorable outcome. The accuracy of the nomogram model in predicting the outcome was 0.923 (95% CI 0.870-0.976), with a cutoff value of 119.6 points. The area under the ROC curve was 0.848 (95% CI 0.780-0.917; sensitivity, 79.7%; specificity, 90.0%).

CONCLUSION

A low Admission NIHSS score, ACLVO at M2, and a small IC volume were positive predictors for favorable outcome. The nomogram model may well predict the outcome in AIS patients with ACLVO after EMT.

The guardian of intracranial vessels: Why the pericyte?

Intracranial atherosclerotic stenosis (ICAS) is a pathological condition characterized by progressive narrowing or complete blockage of intracranial blood vessels caused by plaque formation. This condition leads to reduced blood flow to the brain, resulting in cerebral ischemia and hypoxia. Ischemic stroke (IS) resulting from ICAS poses a significant global public health challenge, especially among East Asian populations. However, the underlying causes of the notable variations in prevalence among diverse populations, as well as the most effective strategies for preventing and treating the rupture and blockage of intracranial plaques, remain incompletely comprehended. Rupture of plaques, bleeding, and thrombosis serve as precipitating factors in the pathogenesis of luminal obstruction in intracranial arteries. Pericytes play a crucial role in the structure and function of blood vessels and face significant challenges in regulating the Vasa Vasorum (VV)and preventing intraplaque hemorrhage (IPH). This review aims to explore innovative therapeutic strategies that target the pathophysiological mechanisms of vulnerable plaques by modulating pericyte biological function. It also discusses the potential applications of pericytes in central nervous system (CNS) diseases and their prospects as a therapeutic intervention in the field of biological tissue engineering regeneration.

Epidemiology, Pathophysiology, and Imaging of Atherosclerotic Intracranial Disease

Intracranial atherosclerotic disease (ICAD) is one of the most common causes of stroke worldwide. Among people with stroke, those of East Asia descent and non-White populations in the United States have a higher burden of ICAD-related stroke compared with Whites of European descent. Disparities in the prevalence of asymptomatic ICAD are less marked than with symptomatic ICAD. In addition to stroke, ICAD increases the risk of dementia and cognitive decline, magnifying ICAD societal burden. The risk of stroke recurrence among patients with ICAD-related stroke is the highest among those with confirmed stroke and stenosis ≥70%. In fact, the 1-year recurrent stroke rate of >20% among those with stenosis >70% is one of the highest rates among common causes of stroke. The mechanisms by which ICAD causes stroke include plaque rupture with in situ thrombosis and occlusion or artery-to-artery embolization, hemodynamic injury, and branch occlusive disease. The risk of stroke recurrence varies by the presumed underlying mechanism of stroke, but whether techniques such as quantitative magnetic resonance angiography, computed tomographic angiography, magnetic resonance perfusion, or transcranial Doppler can help with risk stratification beyond the degree of stenosis is less clear. The diagnosis of ICAD is heavily reliant on lumen-based studies, such as computed tomographic angiography, magnetic resonance angiography, or digital subtraction angiography, but newer technologies, such as high-resolution vessel wall magnetic resonance imaging, can help distinguish ICAD from stenosing arteriopathies.

Association Between Low-Density Lipoprotein-Cholesterol Level and Risk of Intracranial Atherosclerotic Stenosis: Results From the APAC Study

BACKGROUND

It is unknown whether plasma low-density lipoprotein-cholesterol level (LDL-C) can predict the occurrence of intracranial atherosclerotic stenosis (ICAS), especially asymptomatic (A)ICAS. This study investigated whether LDL-C level is independently associated with AICAS.

METHODS

The Asymptomatic Polyvascular Abnormalities Community study is an ongoing community-based, prospective, long-term follow-up observational study with 3387 participants. AICAS was diagnosed by transcranial Doppler ultrasonography. The participants were divided into 3 groups based on LDL-C level. Cox regression was used to evaluate the association between LDL-C level and incidence of AICAS.

RESULTS

During 2 years of follow-up, 9.98% of participants were diagnosed with AICAS. The incidence of AICAS (person-years with 95% CI) was 4.99% (4.48%-5.50%). AICAS incidence did not increase with increasing LDL-C level. Compared with the <2.6 mmol/l subgroup, the incidence of asymptomatic ICAS was not significantly higher in the 2.6 to 3.4 and >3.4 mmol/l subgroups after adjusting for confounding factors (hazard ratio=0.95, 95% CI: 0.86-1.03 and hazard ratio=0.96, 95% CI: 0.84-1.10, respectively).

CONCLUSIONS

LDL-C is not an independent predictor of AICAS incidence in the Chinese population.

The 2023 Taiwan Stroke Society Guidelines for the management of patients with intracranial atherosclerotic disease

Intracranial atherosclerotic disease (ICAD) is a major cause of ischemic stroke, especially in Asian populations, which has a high risk of recurrent stroke and cardiovascular comorbidities. The present guidelines aim to provide updated evidence-based recommendations for diagnosis and management of patients with ICAD. Taiwan Stroke Society guideline consensus group developed recommendations for management of patients with ICAD via consensus meetings based on updated evidences. Each proposed class of recommendation and level of evidence was approved by all members of the group. The guidelines cover six topics, including (1) epidemiology and diagnostic evaluation of ICAD, (2) nonpharmacological management of ICAD, (3) medical therapy for symptomatic ICAD, (4) endovascular thrombectomy and rescue therapy for acute ischemic stroke with underlying ICAD, (5) endovascular interventional therapy for postacute symptomatic intracranial arterial stenosis, and (6) surgical treatment of chronic symptomatic intracranial arterial stenosis. Intensive medical treatment including antiplatelet therapy, risk factor control, and life style modification are essential for patients with ICAD.

Collateral Flow in Intracranial Atherosclerotic Disease

Intracranial atherosclerotic disease (ICAD) is a major cause of ischemic stroke and transient ischemic attack (TIA) worldwide. The culprit of ICAD is frequently a high-grade intracranial atherosclerotic stenosis (ICAS) pertaining to the infarct territory, and by then, the ICAS is described as symptomatic. A high-grade ICAS may progressively limit cerebral perfusion downstream, demanding collateral compensation. Collateral circulation refers to the pre-existing and dynamic emergence of vascular channels that maintain and compensate for a failing principal vascular route. Collaterals through the Circle of Willis and leptomeningeal circulation are of utmost importance in this regard. In this article, we first discussed the epidemiology, stroke mechanisms, contemporary therapeutics, and prognosis of symptomatic ICAD. Then, we reviewed the collateral routes in ICAS, factors associated with recruitment and development of the collaterals and diagnostic imaging modalities in assessing the origin and function of collateral circulation. We discussed the associations between collateral circulation and clinical outcomes after acute reperfusion treatment in ICAD-related ischemic strokes with or without large vessel occlusion (LVO). We also conducted a systematic review and meta-analysis on the associations of collateral circulation with the risk of recurrent stroke and the functional outcome in symptomatic ICAS patients on medical treatment as secondary stroke prevention. Finally, we summarized current evidence in these aspects and proposed the future directions.

A simple score to predict atherosclerotic or embolic intracranial large-vessel occlusion stroke before endovascular treatment

OBJECTIVE

The authors developed a method to predict the etiology of intracranial large-vessel occlusion stroke (ILVOS) before endovascular treatment.

METHODS

The authors retrospectively evaluated two etiologies of ILVOS-intracranial atherosclerotic stenosis-related occlusion (ICAS-O) and embolism-related occlusion (EMB-O)-in a cohort of patients from the National Comprehensive Stroke Center database of China. Patients were randomly divided into the derivation and validation cohorts at a ratio of 2:1. The authors derived the score in the derivation cohort and assessed the score in the validation cohort.

RESULTS

The authors identified 608 of 662 patients with ILVOS who received endovascular treatment during the study period. After adjustment for confounding factors, hypertension (OR 2.90, 95% CI 1.34-6.26), diabetes mellitus (OR 2.80, 95% CI 1.45-5.42), absence of atrial fibrillation (OR 27.29, 95% CI 13.27-56.09), National Institutes of Health Stroke Scale score < 7 (OR 2.92, 95% CI 1.22-6.99), and absence of the computed tomography hyperdense sign (OR 2.86, 95% CI 1.22-6.74) were significantly related to ICAS-O. A score was derived to help predict ICAS-O or EMB-O. The area under the curve values of the receiver operating characteristic curve for ICAS-O identification were 0.886 (95% CI 0.839-0.933) and 0.880 (95% CI 0.846-0.914) in the derivation and validation cohorts, respectively.

CONCLUSIONS

The atrial fibrillation-blood pressure-clinical neurological deficit-computed tomography hyperdense sign-diabetes mellitus (ABC2D) score can be used to identify atherosclerotic or embolic etiology of patients with ILVOS who require emergency endovascular treatment.

Levels of adhesion molecules and clinical outcomes in patients with ischemic stroke after mechanical thrombectomy

Background and purpose

Data on adhesion molecule levels in patients treated with mechanical thrombectomy (MT) are scarce. We aimed to evaluate the association among adhesion molecule levels, symptomatic intracranial hemorrhage (sICH), and clinical outcome and to determine whether the sICH influences the association of adhesion molecules with functional outcome.

Methods

Patients with large artery occlusion in the anterior circulation and treated with MT were prospectively recruited. Adhesion molecules, such as soluble intercellular adhesion molecule-1, soluble vascular cell adhesion molecule-1 (sVCAM-1), and soluble E-selectin (sE-selectin) were tested. An unfavorable outcome was defined as a 90-day modified Rankin Scale (mRS) score of 3–6. The sICH was diagnosed according to the Heidelberg Bleeding Classification within 72 h of endovascular treatment (EVT).

Results

Of the 310 enrolled patients (mean age, 68.5 years; 198 men), 46 (14.8%) experienced sICH and 173 (55.8%) experienced an unfavorable outcome at 90 days. After adjusting for potential confounders, patients with higher sVCAM-1 and sE-selectin levels had an increasing trend of sICH [4th quartile vs. 1st quartile for sVCAM-1; odds ratio (OR), 2.766, p = 0.085; sE-selectin; OR, 2.422, p = 0.086] and poor outcome (4th quartile vs. 1st quartile for sVCAM-1; OR, 2.614, p = 0.025; sE-selectin; OR, 2.325, p = 0.046). Furthermore, the sICH might partially mediate the worse functional outcome in patients with higher adhesion molecules levels (Sobel test, p < 0.001 for sVCAM-1 and p = 0.007 for sE-selectin).

Conclusions

There were significant relationships between levels of adhesion molecules and a 90-day poor outcome in patients with ischemic stroke treated with MT, which was partially mediated by sICH.

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

PURPOSE

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

MATERIAL AND METHODS

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

RESULTS

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

CONCLUSION

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

High Prevalence of Asymptomatic Intracranial Atherosclerosis in Elder Women With Tubal Ligation: Result From a Community-Based Study in Shandong, China

Background

In addition to traditional cardiovascular risk factors, gender-specific factors may also contribute to intracranial atherosclerosis. This study aimed to comprehensively investigate the association between asymptomatic intracranial atherosclerosis (aICAS) and menstrual or reproductive history (MRH), namely, menstruation, pregnancy, childbirth, menopause, and contraception.

Methods

Participants in this study were selected from the Kongcun town aICAS study. MRH was collected through structured case report forms, in which menarche age, menstrual regularity, dysmenorrhea, number of pregnancies, number of childbirths, age of first pregnancy, breastfeeding, menopause, menopause age, and contraceptive methods were all involved. All characteristics were compared by chi-squared and nonparametric tests as applicable. Logistic regression model and sensitivity analysis were used to analyze the association between aICAS and MRH.

Results

A total of 1,052 female participants were involved in this study, of which 5.7% had moderate to severe aICAS. Tubal ligation was significantly associated with aICAS in univariate analysis [crude odds ratio (OR), 2.85; 95% CI, 1.22–6.62; P = 0.015]. This association was still significant among female participants over 60 years old after multivariate adjustment (adjusted OR, 4.36; 95% CI, 1.55–12.24; P = 0.005). Sensitivity analysis showed a similar result (adjusted OR, 3.76; 95% CI, 1.24–11.41; P = 0.020). Menopause lost significant association with aICAS after multivariate adjustment (adjusted OR, 1.68; 95% CI, 0.66–4.24; P = 0.275). No other MRH factors were found to be associated with aICAS.

Conclusion

Tubal ligation may be associated with a higher prevalence of aICAS in Chinese elderly women. This provides a new perspective to study the epidemiological characteristics of ICAS.

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

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

Prevalence and Risk Factors Comparison of Anterior and Posterior Intracranial Arterial Stenosis

The prevalence and risk factors of intracranial atherosclerotic stenosis (ICAS) located in the anterior circulation (AC) and posterior circulation (PC) has been scarcely noted in the general population. We aimed to determine ICAS prevalence and risk factor profile of AC and PC in a representative population. Data were from the China Hypertension Survey of Beijing. In total, 4800 people aged 35 years or older were enrolled in this subsurvey for ICAS, and 3954 participants were eligible for analysis. ICAS was assessed by transcranial Doppler. The prevalence of ICAS in AC was much greater than that in PC (11.9% vs. 4.2%), and subjects with ICAS in PC were 3.9 years older than those with ICAS in AC. Multivariable logistics regression showed that the odds of hypertension and diabetes increased by 79% (OR: 1.79, 95% CI: 1.40-2.27) and 35% (OR: 1.35, 95% CI: 1.04-1.75) in those with AC vascular lesions and by 3.35 times (OR: 3.35, 95% CI: 2.49-4.50) and 71% (OR: 1.71, 95% CI: 1.19-2.46) in those with PC vascular lesions compared with those without vascular lesions. Most modifiable vascular risk factors for ICAS appeared to exert similar magnitudes of risk for PC to AC lesions.

Association of triglyceride-glucose index with intra- and extra-cranial arterial stenosis: a combined cross-sectional and longitudinal analysis

PURPOSE

This study aimed to assess the cross-sectional and longitudinal associations of the triglyceride glucose (TyG) index, a simple surrogate marker of insulin resistance, with intra-cranial and extra-cranial artery stenosis (ICAS and ECAS) in Chinese adults.

METHODS

Participants were recruited from the Asymptomatic Polyvascular Abnormalities Community study, 5381 participants were enrolled in the cross-sectional analysis, then 3447 and 1853 participants in the longitudinal analysis for incident ICAS and ECAS, respectively. The TyG index was calculated as ln [fasting triglyceride (mg/dL) × fasting glucose (mg/dL)/2]. Multivariable logistic analysis was used to calculate odds ratio (OR) and 95% confidence interval (CI).

RESULTS

The results of the cross-sectional and longitudinal analysis were basically the same, as the fully adjusted OR comparing participants in the highest tertile versus lowest tertile of the TyG index was 1.34 (95% CI, 1.13-1.59) for the prevalence of ECAS and 1.85 (95% CI, 1.26-2.71) for incident ECAS, respectively. The addition of TyG index to a conventional model had an incremental effect on the predictive value for ECAS. However, we did not observe any significant association between the TyG index and ICAS.

CONCLUSIONS

Elevated TyG index was significantly associated with a higher risk of ECAS, but not with ICAS in Chinese adults. This conclusion lends support to the clinical significance of the TyG index for the assessment of artery stenosis, especially for ECAS.

Association of remnant cholesterol with intra- and extra-cranial atherosclerosis in Chinese community population

Background

Multifocal atherosclerosis has dramatically increased annual risk of adverse cardiovascular events than single artery affected. Triglyceride-rich lipoprotein (TRL) has been implicated in the early development of atherosclerosis.However, evidence on the effect of remnant cholesterol, a major atherogenic component of TRL, on multifocal atherosclerosis in Chinese health asymptomatic subjects is insufficient. This study aimed to investigate the association of remnant cholesterol with intra- and extra-cranial atherosclerosis in Chinese population.

Methods

This study enrolled 3665 participants (median age 52.31 years) from the Asymptomatic Polyvascular Abnormalities Community study. Parameters of intra- and extra-cranial atherosclerosis includes intracranial artery stenosis (ICAS), carotid plaque, carotid artery stenosis (CAS), and carotid hypertrophy (intima-media thickness >0.9 mm). Logistic regression was used to assess these associations.

Results

The prevalence of vascular atherosclerosis significantly increased with increasing remnant cholesterol quartiles (P for trend <0.0001). In the multivariable-adjusted model, the odds ratio with 95% confidence interval comparing participants in Q4 versus Q1 of remnant cholesterol was 1.73 (1.29-2.31) for ICAS, 1.54 (1.22-1.94) for carotid plaque, 1.47 (1.17-1.84) for CAS, and 1.93 (1.48-2.52) for carotid hypertrophy, respectively. Furthermore, multivariable-adjusted spline regression showed S-shaped associations between remnant cholesterol and these outcomes.

Conclusion

Individuals with a high level of remnant cholesterol had a higher risk of intra- and extra-cranial atherosclerosis in Chinese population. Interventions aimed at reducing remnant cholesterol to prevent atherosclerotic diseases warrant further investigations.

Cervicocerebral atherosclerosis and its hepatic and coronary risk factors in patients with liver cirrhosis

Background/Aims

We aimed to investigate the silent atherosclerotic burden of cervicocephalic vessels in cirrhotic patients compared with the general population, as well as the relevant risk factors including coronary parameters.

Methods

This study included 993 stroke-free patients with liver cirrhosis (LC) who underwent magnetic resonance angiography (MRA) of the head and neck as a pre-liver transplant assessment and 6,099 health checkup participants who underwent MRA examination. The two cohorts were matched for cerebrovascular risk factors, and the prevalence of atherosclerosis in major intracranial and extracranial arteries was compared in 755 matched pairs. Moreover, traditional, hepatic, and coronary variables related to cerebral atherosclerosis were assessed in cirrhotic patients.

Results

Overall, intracranial atherosclerosis was significantly less prevalent in the LC group than in the matched control group (2.3% vs. 5.4%, P=0.002), whereas the prevalence of extracranial atherosclerosis was similar (4.4% vs. 5.8%, P=0.242). These results were maintained in multivariate analyses of the pooled samples, with corresponding adjusted odds ratios [ORs] of LC of 0.56 and 0.77 (95% confidence intervals [CIs], 0.36–0.88 and 0.55–1.09). In the LC group, lower platelet count was inversely correlated with intracranial atherosclerosis (adjusted OR, 0.31; 95% CI, 0.13–0.76). Coronary artery calcium (CAC) score ≥100 was the only predictive factor for both intracranial and extracranial atherosclerosis (adjusted ORs, 4.06 and 5.43, respectively).

Conclusions

LC confers protection against intracranial atherosclerosis, and thrombocytopenia may be involved in this protective effect. High CAC score could serve as a potential surrogate for cervicocerebral vascular screening in asymptomatic cirrhotic patients.

Non-traditional Lipid Parameters as Potential Predictors of Asymptomatic Intracranial Arterial Stenosis

Background: Intracranial arterial stenosis (ICAS) is a common cause of stroke. Identifying effective predictors of ICAS that could be easily obtained in clinical practice is important. The predictive values of serum individual lipid parameters have been well-established. In recent years, several non-traditional lipid parameters demonstrated greater predictive values for cardiovascular disease and ischemic stroke than traditional individual lipid parameters. However, their effects on asymptomatic ICAS (aICAS) are less clear. Therefore, we sought to observe the effects of non-traditional lipid parameters on aICAS. Methods: We enrolled 5,314 participants from the Asymptomatic Polyvascular Abnormalities in Community study. Asymptomatic ICAS was detected by transcranial Doppler ultrasonography (TCD). Non-traditional lipid parameters, including non-high-density lipoprotein cholesterol (non-HDL-C), the triglycerides/high-density lipoprotein cholesterol ratio (TG/HDL-C), atherogenic coefficient (AC), atherogenic index of plasma, and Castelli's risk index (CRI) were measured. We used multivariable logistic analysis to assess the association of different lipid parameters with aICAS; a trend test and subgroup analyses were also performed. Results: In total, 695 of 5,314 participants had aICAS in this study. For the comparison of the highest to the lowest tertile, the multivariable-adjusted odds ratios (ORs) (95% CIs) were 1.78 (1.39-2.27) (p trend < 0.001) for non-HDL-C, 1.48 (1.18-1.85) (p trend = 0.004) for the AC, 1.48 (1.18-1.85) (p trend = 0.004) for CRI-I, and 1.34 (1.09-1.66) (p trend = 0.032) for CRI-II. Subgroup analyses showed significant interactions between the AC, CRI-I, and diabetes. Conclusions: This large community-based study showed that non-HDL-C, AC, CRI-I, and CRI-II were significantly associated with increased prevalence of aICAS.

Acute reperfusion therapies for acute ischemic stroke patients with unknown time of symptom onset or in extended time windows: an individualized approach

Recent randomized controlled clinical trials (RCTs) have revolutionized acute ischemic stroke care by extending the use of intravenous thrombolysis and endovascular reperfusion therapies in time windows that have been originally considered futile or even unsafe. Both systemic and endovascular reperfusion therapies have been shown to improve outcome in patients with wake-up strokes or symptom onset beyond 4.5 h for intravenous thrombolysis and beyond 6 h for endovascular treatment; however, they require advanced neuroimaging to select stroke patients safely. Experts have proposed simpler imaging algorithms but high-quality data on safety and efficacy are currently missing. RCTs used diverse imaging and clinical inclusion criteria for patient selection during the dawn of this novel stroke treatment paradigm. After taking into consideration the dismal prognosis of nonrecanalized ischemic stroke patients and the substantial clinical benefit of reperfusion therapies in selected late presenters, we propose rescue reperfusion therapies for acute ischemic stroke patients not fulfilling all clinical and imaging inclusion criteria as an option in a subgroup of patients with clinical and radiological profiles suggesting low risk for complications, notably hemorrhagic transformation as well as local or remote parenchymal hemorrhage. Incorporating new data to treatment algorithms may seem perplexing to stroke physicians, since treatment and imaging capabilities of each stroke center may dictate diverse treatment pathways. This narrative review will summarize current data that will assist clinicians in the selection of those late presenters that will most likely benefit from acute reperfusion therapies. Different treatment algorithms are provided according to available neuroimaging and endovascular treatment capabilities.

Prevalence and Correlates of Intracranial Atherosclerotic Disease Among Community-Dwelling Older Adults of Amerindian Ancestry. The Three Villages Study

BACKGROUND

Knowledge on the prevalence and correlates of intracranial atherosclerotic disease (ICAD) is limited. We aimed to assess prevalence, clinical and neuroimaging correlates of ICAD in a cohort of older adults of Amerindian ancestry.

METHODS

The study included 581 community-dwellers aged ≥60 years (mean age 71 ± 8.4 years; 57% women) living in rural Ecuadorian villages. ICAD was identified by means of CT determinations of carotid siphon calcifications (CSC) or MRA findings of significant stenosis of intracranial arteries. Fully-adjusted logistic regression models were fitted with biomarkers of ICAD as the dependent variables.

RESULTS

A total of 205 (35%) of 581 participants had ICAD, including 185 with high calcium content in the carotid siphons and 40 with significant stenosis of at least one intracranial artery (20 subjects had both biomarkers). Increasing age, high fasting blood glucose, >10 enlarged basal ganglia-perivascular spaces and non-lacunar strokes were associated with high calcium content in the carotid siphons. In contrast, male gender, moderate-to-severe white matter hyperintensities, lacunar and non-lacunar strokes were associated with significant stenosis of intracranial arteries. Stroke was more common among subjects with any biomarker of ICAD than in those with no biomarkers (29% versus 9%, p < 0.001). Significant stenosis of intracranial arteries was more often associated with stroke than high calcium content in the carotid siphons, suggesting that CSC are more likely an ICAD biomarker than causally related to stroke.

CONCLUSIONS

ICAD prevalence in Amerindians is high, and is significantly associated with stroke. CSC and significant stenosis of intracranial arteries may represent different phenotypes of ICAD.

Hyperglycemia, duration of diabetes, and intracranial atherosclerotic stenosis by magnetic resonance angiography: The ARIC-NCS study

AIMS

The association of hyperglycemia and duration of diabetes with intracranial atherosclerotic stenosis (ICAS) in the general population is not well documented. We examined whether elevated glucose and longer diabetes duration is independently associated with ICAS in a community-based sample.

METHODS

We cross-sectionally analyzed 1644 participants (age 67-90 years) of the Atherosclerosis Risk in Communities Study who underwent cerebrovascular magnetic resonance angiography in 2011-13. We applied multivariable ordinal logistic regression to evaluate the association of ICAS category ("no stenosis", "stenosis <50%", or "stenosis ≥50%") with glucose or diabetes duration (<10, 10 to 20, and ≥20 years). We also obtained the corresponding odds ratios applying inverse-probability weighting to account for potential selection bias due to attrition.

RESULTS

Compared to non-diabetic participants in the lowest glucose quartile, the weighted odds ratios (95% confidence interval) of higher ICAS category were 1.88 (1.18, 3.00) and 2.01 (1.08, 3.72) for non-diabetic and diabetic participants in the corresponding highest glucose quartile, respectively. We observed significant positive trends of ICAS across diabetes duration categories in unweighted, but not in weighted, analyses.

CONCLUSIONS

Hyperglycemia and longer duration of diabetes were independently associated with ICAS, suggesting the importance of maintaining glycemic control to prevent stroke.

Symptomatic Intracranial Hemorrhage After Mechanical Thrombectomy in Chinese Ischemic Stroke Patients: The ASIAN Score

BACKGROUND AND PURPOSE

Symptomatic intracranial hemorrhage (sICH), potentially associated with poor prognosis, is a major complication of endovascular thrombectomy (EVT) for ischemic stroke patients. We aimed to develop and validate a risk model for predicting sICH after EVT in Chinese patients due to large-artery occlusions in the anterior circulation.

METHODS

The derivation cohort recruited patients with EVT from the Endovascular Treatment for Acute Anterior Circulation Ischemic Stroke Registry in China. sICH was diagnosed according to the Heidelberg Bleeding Classification within 24 hours of EVT. Stepwise logistic regression was performed to derive the predictive model. The discrimination and calibration of the risk model were assessed using the C index and the calibration plot. An additional cohort of 503 patients from 2 stroke centers was prospectively enrolled to validate the new model.

RESULTS

We enrolled 629 patients who underwent EVT as the derivation cohort, among whom 87 developed sICH (13.8%). In the multivariate adjustment, Alberta Stroke Program Early CT Score (odds ratio [OR], 0.85; P=0.005), baseline glucose (OR, 1.13; P=0.001), poor collateral circulation (OR, 3.06; P=0.001), passes with retriever (OR, 1.52; P=0.001), and onset-to-groin puncture time (OR, 1.79; P=0.024) were independent factors of sICH and were incorporated as the Alberta Stroke Program Early CT Score, Baseline Glucose, Poor Collateral Circulation, Passes With Retriever, and Onset-to-Groin Puncture Time (ASIAN) score. The ASIAN score demonstrated good discrimination in the derivation cohort (C index, 0.771 [95% CI, 0.716-0.826]), as well as the validation cohort (C index, 0.758 [95% CI, 0.691-0.825]).

CONCLUSIONS

The ASIAN score reliably predicts the risk of sICH in Chinese ischemic stroke patients treated by EVT.

Characterizing lipid profiles associated with asymptomatic intracranial arterial stenosis in rural-dwelling adults: A population-based study

BACKGROUND

Although individual lipid parameters have been frequently examined in association with asymptomatic intracranial arterial stenosis (aICAS), few population-based studies have investigated the lipid profiles associated with aICAS among Chinese adults.

OBJECTIVE

This study aims to characterize the lipid profiles associated with aICAS in rural-dwelling adults in China.

METHODS

This population-based study included 2027 persons who were aged ≥40 years and free of stroke. Data were collected via interviews, clinical examinations, and laboratory testing. We diagnosed aICAS by integrating transcranial color Doppler with magnetic resonance angiography. Data were analyzed using binary and multinomial logistic regression models.

RESULTS

Of the 2027 participants, 154 were detected with aICAS. The multiadjusted odds ratio (95% confidence interval) of aICAS was 1.41 (0.997-2.00) for high small dense low-density lipoprotein cholesterol, 1.44 (1.02-2.04) for high lipoprotein(a), 1.71 (1.21-2.44) for low apolipoprotein A-1, 1.43 (1.00-2.04) for low high-density lipoprotein cholesterol (HDL-C), 1.61 (1.14-2.27) for high apolipoprotein B/apolipoprotein A-1 ratio, 1.95 (1.38-2.76) for high low-density lipoprotein cholesterol/HDL-C ratio, and 1.51 (1.06-2.14) for high total cholesterol/HDL-C ratio. When severity of aICAS was analyzed, high levels of lipoprotein(a), small dense low-density lipoprotein cholesterol, and lipid ratios were significantly associated with an increased likelihood of moderate-to-severe aICAS (P < .05). An increasing number of abnormal lipid measurements was associated with an increased likelihood of aICAS (P for trend <.001).

CONCLUSION

These findings suggest that lipid profiles for aICAS among rural residents in China are characterized by high atherogenic cholesterol, low antiatherogenic cholesterol, and high ratios of atherogenic-to-antiatherogenic cholesterol or lipoproteins.

Prevalence and cardiovascular risk factors of asymptomatic intracranial arterial stenosis: the Kongcun Town Study in Shandong, China

BACKGROUND AND PURPOSE

This study was to investigate the prevalence and cardiovascular risk factors (CRFs) of asymptomatic intracranial atherosclerotic stenosis (aICAS) amongst middle-aged and older adults living in rural communities in China.

METHODS

This population-based study included 2019 subjects (aged ≥40 years, 52.3% women) who were free of stroke and living in rural communities in China. From October 2017 to May 2018, data on demographics, CRFs and health conditions were collected through face-to-face interviews, physical examination and laboratory tests. Asymptomatic ICAS was detected through a two-phase procedure: a screening phase with transcranial Doppler ultrasound, followed by a diagnostic phase with magnetic resonance angiography examination. Multivariable logistic regression models were used to analyse CRFs associated with aICAS.

RESULTS

Of the 2019 participants, aICAS was detected in 153 persons. The overall prevalence of aICAS was 7.6%, and the prevalence of moderate-to-severe aICAS was 5.0%. The multi-adjusted odds ratio (95% confidence interval) of aICAS associated with CRFs was 2.40 (1.56-3.69) for hypertension, 1.91 (1.32-2.76) for high hypersensitive C-reactive protein, 1.68 (1.14-2.49) for diabetes and 1.61 (1.08-2.41) for overweight or obesity. When these four CRFs were aggregated, compared with participants without any of these factors, the multi-adjusted odds ratios (95% confidence interval) of aICAS for persons concurrently having one, two and three or more of these factors were 1.14 (0.52-2.48), 2.91 (1.42-5.99) and 5.51 (2.64-11.50), respectively (P for linear trend <0.001).

CONCLUSIONS

Asymptomatic ICAS is common amongst rural-dwelling middle-aged and older Chinese people. Hypertension, diabetes, overweight or obesity and high hypersensitive C-reactive protein, especially when coexisting, are strongly associated with aICAS.

Concomitant diabetes or hypertension with metabolic syndrome on the extent of intracranial atherosclerotic stenosis

BACKGROUND

Intracranial atherosclerotic stenosis (ICAS) is a major cause of ischemic stroke, especially in Asia. Assessing relationships between novel risk factors and ICAS could lead strategies for improving outcomes. We aimed to evaluate the link between severity of metabolic syndrome (MetS) and extent of ICAS (≥ 50% stenosis).

METHODS

We conducted a cross-sectional study of consecutive Korean patients with acute ischemic stroke, admitted from March 2009 through May 2013, who underwent brain MRI/MRA. Patients were stratified into hypertension only, diabetes mellitus (DM), MetS only, MetS and hypertension, MetS and DM, and neither. MetS was defined using the harmonized criteria.

RESULTS

Of 1220 patients (mean age, 68.2 ± 12.7; female, 42.6%), 238 had hypertension only, 67 DM, 48 MetS only, 311 MetS and hypertension, 403 MetS and DM (88.3% having concomitant hypertension), and 153 neither. Patients with MetS and DM had higher prevalence of ICAS and more ICAS lesions vs. those with neither (all P < 0.001). Compared with neither condition (1.3 ± 0.8), extent of MetS component were greater by increasing MetS severity category (1.7 ± 0.5, 1.8 ± 0.4, 3.3 ± 0.5, 3.4 ± 0.6, and 3.9 ± 0.7, P < 0.001). Odds of ICAS (OR 3.40, 95% CI, 1.82-6.36), ICAS (≥ 2) (4.65, 2.15-10.05), and ICAS (≥ 3) (2.82, 1.02-7.82) remained independently higher in patients with MetS and DM. DM, MetS only, or MetS and hypertension trended towards higher ICAS lesions.

CONCLUSION

MetS and DM along with hypertension is associated with more extensive ICAS than MetS and hypertension or MetS only. Patients with MetS at high risk of hypertension and DM may benefit from therapeutic lifestyle changes to prevent stroke risk.

Elevated Hs-CRP Levels Are Associated with Higher Risk of Intracranial Arterial Stenosis

Correlation between the level of high-sensitivity C-reactive protein (hs-CRP) and the incidence of intracranial arterial stenosis (ICAS) is unclear. We aim to investigate the relationship between hs-CRP levels and ICAS. A total of 1458 patients aged ≥ 40 years were enrolled in this study. All the participants had a magnetic resonance angiography (MRA) examination for the evaluation of ICAS. Participants were classified into four groups according to stroke and ICAS. Multivariable logistic regression models were used to assess the relationship of hs-CRP levels and ICAS status. A total of 432 (29.63%) subjects had ICAS. The levels of hs-CRP in stroke group were significantly higher than those in non-stroke group (p < 0.001). Patients with ICAS tend to have higher hs-CRP levels (p < 0.001). In multivariate analysis, the fourth hs-CRP quartile had the strongest association with ICAS in both stroke group and non-stroke group (OR 2.512, 95% CI 1.651-3.853, p < 0.001 for stroke group, and OR 2.534, 95% CI 1.435-4.595, p = 0.002 for non-stroke group) among the four quartiles of hs-CRP levels. Our study suggests that elevated serum hs-CRP levels are associated with higher risk of ICAS, in both stroke patients and non-stroke participants.

The prevalence of intracranial stenosis in patients at low and moderate risk of stroke

Background:

Previous studies assessing the risk of stroke in the general population performed screening with Doppler ultrasonography only for high-risk patients and neglected low- and moderate-risk patients. The aims of this study were to explore the current prevalence of intracranial arterial stenosis (ICAS) and analyze its association with different levels of stroke risk and risk factors based on the risk assessment scale for stroke used in China.

Methods:

A total of 3654 participants who underwent transcranial Doppler ultrasound (TCD) were eligible for inclusion. Information regarding demographic characteristics and risk factors such as alcohol consumption and hypertension was collected through interviews and questionnaires and used to analyze the association of ICAS with different levels of stroke risk and risk factors.

Results:

The mean age of 501 subjects diagnosed with at least one ICAS was higher than that of participants without ICAS (57.13 ± 9.56 years and 55.52 ± 9.35 years, respectively). After adjusting for confounding factors, gender, education, residence, hypertension and personal history of stroke were associated with ICAS. The odds ratios for ICAS in patients with hypertension and a personal history of stroke were 1.655 [95% confidence interval (CI): 1.341–2.043] and 1.854 (95% CI: 1.371–2.508), respectively. In addition, participants in the low- and moderate-risk stroke groups accounted for an unexpectedly high proportion of individuals with ICAS (up to 38.3%). Results from multivariate analyses indicated that the adjusted odds ratios for ICAS in patients with moderate and high stroke risks versus those with a low stroke risk were 1.603 (95% CI: 1.171–2.195) and 1.612 (95% CI: 1.272–2.042), respectively.

Conclusion:

The prevalence of ICAS is high in northeast China and increases with the level of stroke risk. However, the proportion of patients with ICAS among those with low and moderate stroke risks should also be noted.

Intracranial Artery Stenosis and Its Association With Conventional Risk Factors in a General Population of Japanese Men

Background and Purpose- Few community-based studies have reported the prevalence of intracranial artery stenosis (ICAS) assessed with magnetic resonance angiography. The aim was to determine the prevalence of ICAS using magnetic resonance angiography in a general population of Japanese men and to investigate the associations between ICAS and conventional cardiovascular risk factors. Methods- The Shiga Epidemiological Study of Subclinical Atherosclerosis randomly recruited and examined participants from Kusatsu City, Shiga, Japan, in 2006 to 2008 (baseline); 740 men returned for follow-up and underwent 1.5 T brain magnetic resonance angiography in 2012 to 2015. Participants were categorized as having no-ICAS, mild-ICAS (1 to <50%), or severe-ICAS (≥50%) in any of the arteries examined. After excluding the men with a history of stroke, 709 men were analyzed using multivariable logistic regression to assess independent associations of conventional cardiovascular risk factors with reference to the no-ICAS group. Results- The participants' mean age was 68.0 years. The age-standardized prevalences of mild and severe-ICAS were 20.7% and 4.5%, respectively (with the population of the 2010 Japanese vital statistics as the reference). Age, hypertension, diabetes mellitus, and dyslipidemia were associated with a higher prevalence of severe-ICAS after simultaneous adjustment for conventional cardiovascular risk factors. Conclusions- In a community-based sample of Japanese men, ICAS was estimated to be present in 25.2%, and related to metabolic risk factors, in addition to hypertension and age. These results support the importance of comprehensive management of conventional cardiovascular risk factors for stroke prevention.

Longitudinal association between serum uric acid levels and multiterritorial atherosclerosis

Multiterritorial atherosclerosis has dramatically increased annual risk of adverse cardiovascular events than atherosclerotic disease with single-artery affected. Serum uric acid (SUA) is an important predictor of stroke and atherosclerosis; however, which is supported by few direct evidence based on cohort studies. A prospective cohort study including 2644 North Chinese adults aged ≥40 years was performed in 2010-2012 to investigate the association between SUA and multiterritorial vascular stenosis. Hyperuricaemia was defined as SUA levels >6 and >7 mg/dL for males and females, respectively. All participants underwent twice transcranial Doppler (TCD) and bilateral carotid duplex ultrasound to evaluate intracranial artery stenosis (ICAS) and extracranial arterial stenosis (ECAS) and peripheral arterial disease (PAD) was determined by ankle-brachial index (ABI) on January 2010 and January 2012 based on regular health check-ups. The cumulative incidence of vascular stenosis was significantly higher in subjects with hyperuricaemia than in those without hyperuricaemia (54.1% vs. 34.7%, P < 0.001). The adjusted odds ratios (ORs) with 95% confidence intervals (CIs) for new on-set vascular stenosis due to hyperuricaemia and a 1-mg/dL change in SUA level were 1.75 (1.32-2.31) and 1.29 (1.21-1.38), respectively. Furthermore, in the gender-stratified analysis, the association between SUA levels and ICAS was statistically significant in males (OR: 2.02; 95% CI: 1.18-3.46), but not females (OR: 0.85, 95% CI: 0.41-1.76, P for interaction: 0.026).

Racial Differences in Prevalence and Risk for Intracranial Atherosclerosis in a US Community-Based Population

Importance

Intracranial atherosclerotic disease (ICAD) is an important cause of stroke; however, little is known about racial differences in ICAD prevalence and its risk factors.

Objective

To determine racial differences in ICAD prevalence and the risk factors (both midlife and concurrent) associated with its development in a large, US community-based cohort.

Design, Setting, and Participants

Analysis of 1752 black and white participants recruited from the Atherosclerosis Risk in Communities (ARIC) cohort study who underwent 3-dimensional intracranial vessel wall magnetic resonance imaging from October 18, 2011 to December 30, 2013; data analysis was performed from October 18, 2011 to May 13, 2015.

Exposures

Midlife and concurrent cardiovascular risk factors.

Main Outcomes and Measures

Intracranial plaque presence, size (maximum normalized wall index) and number were assessed by vessel wall magnetic resonance imaging. Midlife and concurrent vascular risk factor associations were determined by Poisson regression (plaque presence), negative binominal regression (plaque number), and linear regression (plaque size), and compared between races.

Results

Of the 1752 study participants (mean [SD] age, 77.6 [5.3] years; range, 67-90 years), 1023 (58.4%) were women and 518 (29.6%) were black. Black men had the highest prevalence (50.9% vs 35.9% for black women, 35.5% for white men, and 30.2% for white women; P < .001) and the highest frequency (22.4% vs 12.1% for black women, 10.7% for white men, and 8.7% for white women; P < .01) of multiple plaques. Prevalence increased with age, reaching 50% before ages 68, 84, and 88 years in black men, white men, and white women, respectively (ICAD prevalence remained <50% in black women). Midlife hypertension and hyperlipidemia were associated with 29% (prevalence ratio [PR], 1.29; 95% CI, 1.08-1.55) and 18% (PR, 1.18; 95% CI, 0.98-1.42), respectively, increased ICAD prevalence with no significant differences between races. Midlife hypertension was also associated with larger plaques (1.11 higher mean maximum normalized wall index; 95% CI, 0.21-2.01). Midlife smoking and diabetes were associated with increased risk of ICAD in black individuals (102% [PR, 2.02; 95% CI, 1.12-3.63] and 57% [PR, 1.57; 95% CI, 1.13- 2.19], respectively), but not in white participants (P < .05 interaction by race).

Conclusions and Relevance

The prevalence of ICAD was highest in black men. Midlife smoking and diabetes were strongly associated with late-life ICAD in blacks only, whereas midlife hypertension and hyperlipidemia were associated with late-life ICAD in both races. These associations may help to explain racial differences in US stroke rates and offer insight into preventive risk-factor management strategies.

Urine albumin-to-creatinine ratio and asymptomatic intracranial atherosclerotic stenosis in hypertensive patients

Intracranial atherosclerotic stenosis (ICAS) contributes to nearly 50% of stroke in China, especially in patients with hypertension. Urine albumin-to-creatinine ratio (ACR) has been related to stroke and other atherosclerotic cardiovascular diseases. However, there is limited information about the association of ACR and early impairment of cerebral vessels. Hereby we assessed the association of ICAS with ACR, estimated glomerular filtration rate (eGFR), and dipstick proteinuria in a stroke-free hypertensive population. We included 889 hypertension patients aged ≥60 years without prior stroke. Computed tomography angiography was performed to detect ICAS. ACR and dipstick proteinuria were tested from a random spot urine. eGFR was calculated using the CKD-EPI equation. Logistic regression was carried out to analyze the association of renal function with the presence, extent, and lesion number of ICAS. Elevated ACR (≥30 mg/g) was associated with ICAS after adjustment of confounding factors (odds ratio (OR) = 1.66, 95% confidence interval (CI): 1.21-2.29). Patients with elevated ACR were more prone to develop moderate-to-severe stenosis (OR = 1.57, 95% CI: 1.16-2.14) and more lesions (OR = 1.58, 95% CI: 1.16-2.15). Such association was independent of previously identified cardiovascular risk factors. No significant association was detected between ICAS and dipstick proteinuria or eGFR after adjustment. Our findings suggested that elevated ACR was associated with asymptomatic ICAS in an aged stroke-free hypertensive population.

Association of ATP2B1 common variants with asymptomatic intracranial and extracranial large artery stenosis in hypertension patients

BACKGROUND AND AIMS

Genetic factors play an important role in the cervico-cerebral large-artery atherosclerotic stenosis (LAS), and ATP2B1 gene has been associated with the process of atherosclerosis disorders, such as coronary artery disease and arterial stiffness. But there is little information about the relationship between ATP2B1 gene and atherosclerosis in the intracranial arteries. We hereby investigated the association of common variants in ATP2B1 gene with LAS in asymptomatic Chinese hypertension patients.

METHODS

The stenosis of intracranial and extracranial arteries were evaluated in 899 subjects through computerized tomography angiography from the aortic arch to the skull base. A total of 11 ATP2B1 common variants were genotyped. Multivariate logistic regression was carried out in a dominant model with confounding factors adjusted.

RESULTS

rs17249754-A (OR = 0.43, p = 0.0002) and rs1401982-G (OR = 0.47, p = 0.0007) were associated with decreased susceptibility of concurrent extra and intracranial stenosis even after Bonferroni correction. These two minor alleles were also significantly associated with less stenotic arteries and moderate-to-severe stenosis.

CONCLUSION

rs17249754 and rs1401982 were associated with asymptomatic LAS in stroke-free Chinese hypertension patients and might benefit early recognition of LAS patients in clinical practice.

Intracranial artery stenosis: Current status of evaluation and treatment in China

Intracranial artery stenosis (ICAS), a common cause of ischemic stroke, is a growing cause of concern in China. Recently, many epidemiological, etiological, pathophysiological, therapy, and diagnostic imaging studies have focused on ICAS, and guidelines and consensus on the diagnosis and treatment of ICAS have been published and updated by domestic experts. Such work is pivotal to our enhanced comprehension, diagnosis, and treatment of ICAS. In this review, we summarize the latest progress in the evaluation and treatment of ICAS in China.

Histological Characteristics of Intracranial Atherosclerosis in a Chinese Population: A Postmortem Study

Background

Anterior and posterior circulation atherosclerosis differ in vascular risk factors and stroke mechanisms. However, few studies have compared the pathological features between these lesions. Using a series of intracranial artery specimens, we characterized the intracranial atherosclerotic lesions and compared pathological features among different arteries of the intracranial vasculature.

Methods

Intracranial large arteries of 32 consecutively recruited autopsy cases of Chinese adults aged 45 years or older were examined pathologically using routine histology and immunostaining, to characterize the pathological features of the atherosclerotic lesions. We analyzed middle cerebral arteries (MCAs) (both left and right), vertebral arteries (VAs) (side more affected), and basilar arteries (BAs).

Results

Progressive atherosclerotic lesions were present in 91(71%) of the 128 arteries examined. Features of complicated plaques were infrequently detected: plaque hemorrhage was encountered in 12%, neovasculature in 12%, lumen thrombi in 13%, macrophage infiltration in 20%, and calcification in 25% of arteries. Luminal narrowing of MCA was the most severe, followed by VA; the BA least stenotic (37 ± 25 vs. 30 ± 24 vs. 20 ± 20%, all p < 0.05). MCA had more eccentric (vs. concentric) plaques than VA (69 vs. 25%, p = 0.003) and BA (69 vs. 38%; p = 0.03). Lumen thrombi were more frequent in BA, and calcification most commonly occurred in VA atherosclerotic lesions.

Conclusion

Intracranial atherosclerotic plaques were commonly present in this sample, but the lesions generally lacked features of complicated plaques. MCA lesions had demonstrable differences compared with VA and BA lesions. Further studies are needed to determine whether these characteristics indicate a distinctive atherosclerotic phenotype for the intracranial vasculature.

Comparison of type 2 diabetes prevalence in Chinese migrants vs Caucasians and new perspectives for screening of cerebrovascular disease in Chinese: A proof of concept study

AIMS

Type 2 diabetes (T2DM) is a recognized risk factor for intracranial stenosis (ICS) in China where ischemic stroke is a health priority. In Europe little information is available on T2DM prevalence among Chinese minority groups and vascular screening is commonly limited to extracranial vessels. Feasibility of community-based T2DM screening, differences in T2DM prevalence between Chinese migrants and Italians, and prevalence of ICS among Chinese patients with newly diagnosed T2DM were investigated.

METHODS

Chinese first generation migrants (n=1200) and native Italians (n=291) aged 35-59years were enrolled in a cross-sectional survey. Diagnosis of T2DM was based on fasting plasma glucose and/or current treatment with glucose-lowering drugs. Newly diagnosed Chinese patients were screened for ICS using Doppler ultrasound.

RESULTS

T2DM was more prevalent among Chinese (n=168, 14.0%) than Italians (n=21, 7.3%) (age- and gender adjusted OR 2.29; 95% C.L. 1.41-3.72). Prevalence of ICS among newly diagnosed Chinese was 18.2%. Nine out of the 17 patients with any ICS (52%) had >1 intracranial lesion.

CONCLUSIONS

T2DM screening within the Chinese community was feasible revealing prevalence twice as much as in the Italian cohort; the 18% prevalence of ICS in newly diagnosed Chinese patients stresses the need of implementing appropriate vascular screening strategies.

Relation of Ideal Cardiovascular Health Metrics to Asymptomatic Polyvascular Disease in a Chinese Population

Atherosclerosis is a systemic disease with manifestations in multiple vascular beds. Ideal cardiovascular health (CVH) metrics relate to cardiovascular and cerebrovascular disease. However, the relation between ideal CVH metrics and asymptomatic polyvascular disease (polyVD) is unknown. We collected information on the 7 CVH metrics among 5,224 participants aged ≥40 years from 2010 to 2011. Intracranial artery stenosis, extracranial artery stenosis, and lower extremity artery disease were detected by transcranial Doppler, duplex sonography, and by calculating ankle-brachial index. Ordinal logistic regression and linear models were used to analyze the relation between ideal CVH metrics and polyVD. PolyVD was identified in 158 (3%) participants. We observed a significant inverse gradient relation between the number of ideal CVH metrics and prevalence of polyVD after adjustment for potential confounders. The adjusted odds ratios and 95% confidence intervals were 0.824 (0.657 to 1.032), 0.641 (0.511 to 0.804), 0.538 (0.423 to 0.684), 0.583 (0.442 to 0.769), and 0.530 (0.348 to 0.808) for those having 2, 3, 4, 5, and 6 or 7 ideal CVH metrics, respectively, compared with those having 0 or 1 ideal CVH metric (p-trend <0.0001). Similarly, a larger number of ideal CVH metrics was associated with a lower prevalence of polyVD in the linear models (adjusted β coefficient -0.030, 95% confidence interval -0.041 to -0.020). Stratification for gender and age yielded consistent results in all subgroups except for women subgroup. In conclusion, we observed a significant inverse gradient association between the number of ideal CVH metrics and prevalence of asymptomatic polyVD.

Intracranial stenosis in cognitive impairment and dementia

Intracranial stenosis is a common vascular lesion observed in Asian and other non-Caucasian stroke populations. However, its role in cognitive impairment and dementia has been under-studied. We, therefore, examined the association of intracranial stenosis with cognitive impairment, dementia and their subtypes in a memory clinic case-control study, where all subjects underwent detailed neuropsychological assessment and 3 T neuroimaging including three-dimensional time-of-flight magnetic resonance angiography. Intracranial stenosis was defined as ≥50% narrowing in any of the intracranial arteries. A total of 424 subjects were recruited of whom 97 were classified as no cognitive impairment, 107 as cognitive impairment no dementia, 70 vascular cognitive impairment no dementia, 121 Alzheimer's Disease, and 30 vascular dementia. Intracranial stenosis was associated with dementia (age/gender/education - adjusted odds ratios (OR): 4.73, 95% confidence interval (CI): 1.93-11.60) and vascular cognitive impairment no dementia (OR: 3.98, 95% CI: 1.59-9.93). These associations were independent of cardiovascular risk factors and MRI markers. However, the association with Alzheimer's Disease and vascular dementia became attenuated in the presence of white matter hyperintensities. Intracranial stenosis is associated with vascular cognitive impairment no dementia independent of MRI markers. In Alzheimer's Disease and vascular dementia, this association is mediated by cerebrovascular disease. Future studies focusing on perfusion and functional markers are needed to determine the pathophysiological mechanism(s) linking intracranial stenosis and cognition so as to identify treatment strategies.

Predictors for Symptomatic Intracranial Hemorrhage After Endovascular Treatment of Acute Ischemic Stroke

Background and Purpose—

Symptomatic intracranial hemorrhage (SICH) pose a major safety concern for endovascular treatment of acute ischemic stroke. This study aimed to evaluate the risk and related factors of SICH after endovascular treatment in a real-world practice.

Methods—

Patients with stroke treated with stent-like retrievers for recanalizing a blocked artery in anterior circulation were enrolled from 21 stroke centers in China. Intracranial hemorrhage was classified as symptomatic and asymptomatic ones according to Heidelberg Bleeding Classification. Logistic regression was used to identify predictors for SICH.

Results—

Of the 632 enrolled patients, 101 (16.0%) were diagnosed with SICH within 72 hours after endovascular treatment. Ninety-day mortality was higher in patients with SICH than in patients without SICH (65.3% versus 18.8%; P <0.001). On multivariate analysis, baseline neutrophil ratio >0.83 (odds ratio [OR], 2.07; 95% confidence interval [CI], 1.24–3.46), pretreatment Alberta Stroke Program Early Computed Tomography Score of <6 (OR, 2.27; 95% CI, 1.24–4.14), stroke of cardioembolism type (OR, 1.91; 95% CI, 1.13–3.25), poor collateral circulation (OR, 1.97; 95% CI, 1.16–3.36), delay from symptoms onset to groin puncture >270 minutes (OR, 1.70; 95% CI, 1.03–2.80), >3 passes with retriever (OR, 2.55; 95% CI, 1.40–4.65) were associated with SICH after endovascular treatment.

Conclusions—

Incidence of SICH after thrombectomy is higher in Asian patients with acute ischemic stroke. Cardioembolic stroke, poor collateral circulation, delayed endovascular treatment, multiple passes with stent retriever device, lower pretreatment Alberta Stroke Program Early Computed Tomography Score, higher baseline neutrophil ratio may increase the risk of SICH.

Asymptomatic polyvascular disease and the risks of cardiovascular events and all-cause death

BACKGROUND AND AIMS

Atherosclerosis is a diffuse and systemic disease. We aimed to assess prevalence and outcome of extracoronary polyvascular disease (polyVD) in the asymptomatic Chinese community population.

METHODS

A random sample of 5440 participants aged 40 years or older were enrolled in the Asymptomatic Polyvascular Abnormalities Community Study from 2010 to 2011. Intracranial artery stenosis, extracranial artery stenosis, and lower extremity artery disease were detected by transcranial Doppler and duplex sonography, and by calculating the ankle brachial index. The study endpoints included the first occurrence of stroke, myocardial infarction (MI) and all-cause death.

RESULTS

PolyVD (two or three affected vascular territories) was found in 3.0% of the participants, and was significantly higher in men (4.3%). Over a median follow-up of 4.1 years, we identified a total of 247 events (4.7%), including 83 strokes (68 ischemic), 45 MIs and 134 all-cause deaths. After adjusting for age, gender and other potential confounders, we found a significant increase in risk of major cardiovascular events as well as all-cause death in participants with polyVD. In multivariate Cox regression analyses, the adjusted hazard ratios (HR) (95% confidence interval, CI) for the composite of stroke, MI and all-cause death for single and poly-vascular disease (compared with 0 vascular disease) increased from 1.58 (1.19-2.12) to 1.95 (1.26-3.03). Similarly, the adjusted HR (95% CI) for all-cause death for single and poly-vascular disease increased from 1.53 (1.03-2.29) to 2.22 (1.27-3.86).

CONCLUSIONS

PolyVD significantly increased the risk of major cardiovascular events and all-cause death in the asymptomatic community population. Performing invasive screening tests for polyVD is useful in the high-risk asymptomatic population.

Association between High-density-lipoprotein-cholesterol Levels and the Prevalence of Asymptomatic Intracranial Arterial Stenosis

Intracranial atherosclerotic stenosis (ICAS) is a common cause of ischemic stroke, and a low level of high-density lipoprotein cholesterol (HDL-C) is also considered to be a predictor for stroke. However, the association between the HDL-C level and asymptomatic ICAS is uncertain. From 2010 to 2011, a random sample of 5,351 participants were enrolled in the Asymptomatic Polyvascular Abnormalities Community (APAC) study. The recruited participants were then separated into 5 roughly uniform-sized factions with varying HDL-C levels. Multivariate logistic regression was implemented to assess the connection of the HDL-C levels and the prevalence of asymptomatic ICAS. The prevalence of asymptomatic ICAS showed no gradual decrease with the increase of HDL-C levels. After adjustment for conventional risk factors, HDL-C levels still showed no significant association with asymptomatic ICAS. The odds ratios (OR) of the prevalence of asymptomatic ICAS between the first group and the other 4 groups were 0.98, 1.00, 0.92, and 0.87 with 95% confidence intervals (CI) being 0.76–1.27, 0.78–1.29, 0.71–1.19, and 0.66–1.13, respectively. The study showed little correlation between HDL-C levels and asymptomatic ICAS. Normal levels of HDL-C are not an independent risk factor for asymptomatic ICAS.

Prevalence of stroke and associated risk factors among middle-aged and older farmers in western China

Objectives

China has the world’s largest population and the stroke has become the leading cause of death in recent years. The purpose of this study was to explore the associations between hypertension, family history of stroke, diabetes mellitus, obesity and stroke among middle-aged and older farmers of western China. A population-based study was conducted from June 2014 to April 2015 in Shaanxi and Sichuan provinces.

Methods

Twenty thousand five hundred twenty-five Chinese middle-aged and older farmers (≥40 years) were recruited to the Qinling-Daba Mountains Region Stroke Study. A structured-questionnaire was used to collect data through face-to-face interviews. Demographic characteristics, risk factors, medical history, and other clinical characteristics were recorded for all participants. The association between hypertension, family history of stroke, diabetes mellitus, obesity and stroke were analyzed by using univariate and multivariate logistic regression analysis.

Results

The stoke prevalence rate was 1380/100,000 in middle-aged and older farmers of western China. The difference in hypertension, diabetes mellitus, obesity and family history between different age groups had statistical significance (p < 0.05). The prevalence rate of hypertension and family history of stroke were higher in male population than in the female population. The difference was statistically significant (p < 0.05). Univariate logistic regression analysis demonstrated age, gender, hypertension, obesity and family history of stroke were stroke risk factors (p < 0.05). Multivariate logistic regression analysis revealed that the odds ratios of family history of stroke, obesity and hypertension were 7.177, 4.389 and 3.647 respectively.

Conclusions

Family history is the strongest stroke risk factor in middle-aged and older farmers of western China.

Stroke Caused by Atherosclerosis of the Major Intracranial Arteries

Our goal in this review is to discuss the pathophysiology, diagnosis, and treatment of stroke caused by atherosclerosis of the major intracranial arteries. References for the review were identified by searching PubMed for related studies published from 1955 to June 2016 using search terms intracranial stenosis and intracranial atherosclerosis. Reference sections of published randomized clinical trials and previously published reviews were searched for additional references. Intracranial atherosclerotic disease is a highly prevalent cause of stroke that is associated with a high risk of recurrent stroke. It is more prevalent among blacks, Hispanics, and Asians compared with whites. Diabetes mellitus, hypertension, metabolic syndrome, smoking, hyperlipidemia, and a sedentary lifestyle are the major modifiable risk factors associated with intracranial atherosclerotic disease. Randomized clinical trials comparing aggressive management (dual antiplatelet treatment for 90 days followed by aspirin monotherapy and intensive management of vascular risk factors) with intracranial stenting plus aggressive medical management have shown medical management alone to be safer and more effective for preventing stroke. As such, aggressive medical management has become the standard of care for symptomatic patients with intracranial atherosclerotic disease. Nevertheless, there are subgroups of patients who are still at high risk of stroke despite being treated with aggressive medical management. Future research should aim to establish clinical, serological, and imaging biomarkers to identify high-risk patients, and clinical trials evaluating novel therapies should be focused on these patients.

Non-High-Density Lipoprotein Cholesterol Levels on the Risk of Asymptomatic Intracranial Arterial Stenosis: A Result from the APAC Study

Intracranial arterial stenosis (ICAS) is an important cause of ischemic stroke and transient ischemic attack (TIA), and the correlation between the plasma non-high density cholesterol (non-HDLC) levels and ICAS, especially asymptomatic ICAS (AICAS) is not clear. The Asymptomatic Polyvascular Abnormalities Community(APAC) study is a community-based, prospective, long-term follow-up observational study. 3387 participants were enrolled in this study. The diagnosis of AICAS was made by transcranial Doppler ultrasonography. The participants were then divided into 3 groups based on their non-HDLC levels. The cox regression was used to analyze the correlation between the non-HDLC level and the incidence of AICAS.9.98% of the participants were diagnosed with AICAS during 2 years following up. Multivariate analysis showed that non-HDL-C is an independent indicator for the incidence of AICAS (HR = 1.22, 95%CI: 1.06–1.40), The incidence of AICAS gradually increase with the increasing non-HDLC level. Compared with subgroup(non-HDLC < 3.4 mmol/l), incidence of AICAS was significantly higher in the subgroups(non-HDLC 3.4–4.1 mmol/l and non-HDLC ≥ 4.1 mmol/l) after adjustment for the confounding factors (HR = 1.32, 95%CI:1.02–1.73; HR = 1.46, 95%CI: 1.10–1.94, respectively). In conclusions, our findings suggest that elevated non-HDLC levels a significant risk factor for the development of AICAS in the APAC study.

China suboptimal health cohort study: rationale, design and baseline characteristics

BACKGROUND

Suboptimal health status (SHS) is a physical state between health and disease, characterized by the perception of health complaints, general weakness, chronic fatigue and low energy levels. SHS is proposed by the ancient concept of traditional Chinese medicine (TCM) from the perspective of preservative, predictive and personalized (precision) medicine. We previously created the suboptimal health status questionnaire 25 (SHSQ-25), a novel instrument to measure SHS, validated in various populations. SHSQ-25 thus affords a window of opportunity for early detection and intervention, contributing to the reduction of chronic disease burdens.

METHODS/DESIGN

To investigate the causative effect of SHS in non-communicable chronic diseases (NCD), we initiated the China suboptimal health cohort study (COACS), a longitudinal study starting from 2013. Phase I of the study involved a cross-sectional survey aimed at identifying the risk/protective factors associated with SHS; and Phase II: a longitudinal yearly follow-up study investigating how SHS contributes to the incidence and pattern of NCD.

RESULTS

(1) Cross-sectional survey: in total, 4313 participants (53.8 % women) aged from 18 to 65 years were included in the cohort. The prevalence of SHS was 9.0 % using SHS score of 35 as threshold. Women showed a significantly higher prevalence of SHS (10.6 % in the female vs. 7.2 % in the male, P < 0.001). Risk factors for chronic diseases such as socioeconomic status, marital status, highest education completed, physical activity, salt intake, blood pressure and triglycerides differed significantly between subjects of SHS (SHS score ≥35) and those of ideal health (SHS score <35). (2) Follow up: the primary and secondary outcomes will be monitored from 2015 to 2024.

CONCLUSIONS

The sex-specific difference in prevalence of SHS might partly explain the gender difference of incidence of certain chronic diseases. The COACS will enable a thorough characterization of SHS and establish a cohort that will be used for longitudinal analyses of the interaction between the genetic, lifestyle and environmental factors that contribute to the onset and etiology of targeted chronic diseases. The study together with the designed prospective cohort provides a chance to characterize and evaluate the effect of SHS systemically, and it thus generates an unprecedented opportunity for the early detection and prevention of chronic disease.

Peak Systolic Velocity Measurements with Transcranial Doppler Ultrasound Is a Predictor of Incident Stroke among the General Population in China

BACKGROUND AND OBJECTIVE

It is necessary to develop an effective and low-cost screening tool for identifying Chinese people at high risk of stroke. Transcranial Doppler ultrasound (TCD) is a powerful predictor of stroke in the pediatric sickle cell disease population, as demonstrated in the STOP trial. Our study was conducted to determine the prediction value of peak systolic velocities as measured by TCD on subsequent stroke risk in a prospective cohort of the general population from Beijing, China.

METHODS

In 2002, a prospective cohort study was conducted among 1392 residents from 11 villages of the Shijingshan district of Beijing, China. The cohort was scheduled for follow up with regard to incident stroke in 2005, 2007, and 2012 by a study team comprised of epidemiologists, nurses, and physicians. Univariate and multivariate Cox proportional hazard regression models were used to determine the factors associated with incident stroke.

RESULTS

Participants identified by TCD criteria as having intracranial stenosis had a 3.6-fold greater risk of incident stroke (hazard ratio (HR) 3.57, 95% confidence interval (CI) 1.86-6.83, P<0.01) than those without TCD evidence of intracranial stenosis. The association remained significant in multivariate analysis (HR 2.53, 95% CI 1.31-4.87) after adjusting for other risk factors or confounders. Older age, cigarette smoking, hypertension, and diabetes mellitus remained statistically significant as risk factors after controlling for other factors.

CONCLUSIONS

The study confirmed the screening value of TCD among the general population in urban China. Increasing the availability of TCD screening may help identify subjects as higher risk for stroke.

Italian symptomatic intracranial atherosclerosis study (ISIDE) : A multicenter transcranial ultrasound evaluation

There are currently no data available on the prevalence of symptomatic intracranial atherosclerosis (ICAS) in Italy. The aim of this prospective, multicenter, hospital-based, transcranial ultrasound study was to establish the prevalence of ICAS among patients hospitalized with acute ischemic stroke. At 11 stroke centers across Italy, patients consecutively admitted for their first ever acute ischemic stroke were assessed prospectively over a 24-month period either with transcranial color-coded Doppler sonography (TCCS) or transcranial Doppler (TCD) according to validated criteria. ICAS was diagnosed when there was an evidence of a cerebral infarction in the territory of a ≥50 % stenosis detected by TCCS/TCD and confirmed by magnetic resonance angiography or computed tomography angiography. A total of 1134 patients were enrolled, 665 of them (58.6 %) men, with a mean age of 71.2 ± 13.3 years. ICAS was recorded in 99 patients (8.7 % of the whole sample, 8.9 % among Caucasians), most commonly located in the anterior circulation (63 of 99, 5.5 %). After adjusting for potential confounders, multivariate analysis identified carotid/vertebral ≥50 % stenosis [odds ratio (OR) 2.59, 95 % (confidence interval) CI 1.77-6.33; P = 0.02] and hypercholesterolemia (OR 1.38, 95 % CI 1.02-1.89; P = 0.02) as being independently associated with ICAS. ICAS is a surprisingly relevant cause of ischemic stroke in Italy, identified in almost 9 % of first-ever stroke patients. It is more prevalent in the anterior circulation and independently associated with hemodynamically significant cervical vessel atherosclerosis and hypercholesterolemia. These findings support the systematic use of transcranial ultrasound to identify ICAS in patients presenting with acute ischemic stroke and in cases with ≥50 % cervical vessel stenoses.