Diabetes, Intracranial Stenosis and Microemboli in Asymptomatic Carotid Stenosis

Lam, Thach; Lammers, Stephanie; Munoz, Claudio; Tamayo, Arturo; Spence, J. David

doi:10.1017/s031716710001369x

Cited by 13 publications

(7 citation statements)

References 25 publications

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“…Intracranial stenosis is more common in Asian patients and in diabetics 69, 70 . The Stenting and Aggressive Medical Management for Preventing Recurrent Stroke in Intracranial Stenosis (SAMMPRIS) trial 71 reported in 2014 that intensive medical therapy that included lifestyle modification was more efficacious than stenting for intracranial stenosis.…”

Section: Intracranial Stenosismentioning

confidence: 99%

Recent advances in preventing stroke recurrence

Spence

2017

F1000Res

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Recent advances in secondary stroke prevention include new evidence in hypertension, nutrition, anticoagulation, antiplatelet therapy, intracranial stenosis, percutaneous closure of patent foramen ovale, and lipid-lowering therapy. Individualized therapy for hypertension based on phenotyping with plasma renin and aldosterone markedly improves blood pressure control in patients with resistant hypertension. A Mediterranean diet can reduce the risk of stroke by nearly half. The diagnosis and treatment of metabolic vitamin B12 deficiency, and B vitamins to lower homocysteine, can reduce the risk of stroke by approximately 30%. There are problems with clopidogrel that can be overcome by using ticagrelor, and new anticoagulant drugs markedly improve anticoagulation for stroke prevention, particularly in atrial fibrillation. There are pharmacokinetic problems with dabigatran that deserve attention. Intensive medical therapy is better than stenting for intracranial stenosis, and new therapies directed at proprotein convertase subtilisin–kexin type 9 (PCSK9) will revolutionize lipid-lowering therapy. In the past, it was estimated that rational therapy could reduce recurrent stroke by about 80%. With recent advances, we should be able to do even better.

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Section: Intracranial Stenosismentioning

confidence: 99%

Recent advances in preventing stroke recurrence

Spence

2017

F1000Res

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“…Caplan has suggested4 that microatheroma may account for some of small vessel disease. This may be more common in diabetes mellitus, another cause of ‘small vessel disease’, and which is associated with a higher prevalence of intracranial stenosis of larger arteries 5. Recently he pointed out6 that conditions ‘that affect small arterioles and capillaries originating from peripheral branches of the large intracranial arteries that supply blood to the more superficial regions of the brain’ are heterogeneous.…”

Section: Introductionmentioning

confidence: 99%

Blood pressure gradients in cerebral arteries: a clue to pathogenesis of cerebral small vessel disease

2017

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RationaleThe role of hypertension in cerebral small vessel disease is poorly understood. At the base of the brain (the ‘vascular centrencephalon’), short straight arteries transmit blood pressure directly to small resistance vessels; the cerebral convexity is supplied by long arteries with many branches, resulting in a drop in blood pressure. Hypertensive small vessel disease (lipohyalinosis) causes the classically described lacunar infarctions at the base of the brain; however, periventricular white matter intensities (WMIs) seen on MRI and WMI in subcortical areas over the convexity, which are often also called ‘lacunes’, probably have different aetiologies.ObjectivesWe studied pressure gradients from proximal to distal regions of the cerebral vasculature by mathematical modelling.Methods and resultsBlood flow/pressure equations were solved in an Anatomically Detailed Arterial Network (ADAN) model, considering a normotensive and a hypertensive case. Model parameters were suitably modified to account for structural changes in arterial vessels in the hypertensive scenario. Computations predict a marked drop in blood pressure from large and medium-sized cerebral vessels to cerebral peripheral beds. When blood pressure in the brachial artery is 192/113 mm Hg, the pressure in the small arterioles of the posterior parietal artery bed would be only 117/68 mm Hg. In the normotensive case, with blood pressure in the brachial artery of 117/75 mm Hg, the pressure in small parietal arterioles would be only 59/38 mm Hg.ConclusionThese findings have important implications for understanding small vessel disease. The marked pressure gradient across cerebral arteries should be taken into account when evaluating the pathogenesis of small WMIs on MRI. Hypertensive small vessel disease, affecting the arterioles at the base of the brain should be distinguished from small vessel disease in subcortical regions of the convexity and venous disease in the periventricular white matter.

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“…Second, we knew there are some subtypes of stroke in literatures and patients with diabetes are more likely to have intracranial stenosis. 27 The ischemic stroke still accounted for most of the stroke in China 7 although in general the hemorrhagic strokes in Chinese are common than western population. Unfortunately, in the present study we do not have sufficient information to satisfactorily classify the sub-types of stroke.…”

Section: Discussionmentioning

confidence: 99%