AJNR Am J Neuroradiol

2012

DOI: 10.3174/ajnr.a3015

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Severity of Leukoaraiosis in Large Vessel Atherosclerotic Disease

Aurauma Chutinet

¹

,

Alessandro Biffi

²

,

Allison Kanakis

³

et al.

Abstract: BACKGROUND AND PURPOSE:The severity of white matter hyperintensity, or leukoaraiosis, is a marker of cerebrovascular disease. In stroke, WMH burden is strongly linked to lacunar infarction; however, impaired cerebral perfusion due to extracranial or intracranial atherosclerosis may also contribute to WMH burden. We sought to determine whether WMH burden is associated with extracranial or intracranial stenosis in patients with AIS.

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Cited by 42 publications

(36 citation statements)

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“…Our finding of an association of age with WML severity is in line with previous findings [20,29]. In the present study, the previous association of AHT with WMLs [20,29,30] was not replicated, which may be due to heterogeneity of the definition of hypertension including those with diagnosed hypertension under control and those without response.…”

Section: Discussionsupporting

confidence: 90%

“…In the present study, the previous association of AHT with WMLs [20,29,30] was not replicated, which may be due to heterogeneity of the definition of hypertension including those with diagnosed hypertension under control and those without response. Both the frequency of dyslipidemia and smoking decreased with increasing WML severity, in line with a previous study [20].…”

Section: Discussioncontrasting

confidence: 75%

See 1 more Smart Citation

Preoperative White Matter Lesions Are Independent Predictors of Long-Term Survival after Internal Carotid Endarterectomy

¹

,

²

,

³

et al. 2014

Cerebrovasc Dis Extra

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Background: Cerebral white matter lesions (WMLs) predict long-term survival of conservatively treated acute stroke patients with etiology other than carotid stenosis. In carotid endarterectomy patients, WMLs are associated with severe carotid stenosis and unstable plaques, with the risk of perioperative complications and with increased 30-day perioperative risk of death. However, no data exist on their effect on postoperative long-term survival, a factor important when considering the net benefit from carotid endarterectomy. Whether this effect is independent of classical risk factors and indications for surgery is not known either. We hypothesized that WMLs could be evaluated from preoperative routine computed tomography (CT) scans and are predictors of postoperative survival, independent of classical cardiovascular risk factors, indication category and degree of carotid stenosis. Methods: A total of 353 of 481 (73.4%) consecutive patients subjected to carotid endarterectomy due to different indications, i.e. asymptomatic stenosis (n = 28, 7.9%), amaurosis fugax (n = 52, 14.7%), transient ischemic attack (n = 135, 38.2%) or ischemic stroke (n = 138, 39.1%), from prospective vascular registries during the years 2001-2010 with digital preoperative CT scans, were included in the study. WMLs were rated by a radiologist (Wahlund criteria) in a blinded fashion. Internal carotid artery (ICA) stenoses were angiographically graded (<50, 50-69, 70-99 and 100%). Odds ratios (ORs) and hazard ratios (HRs) are reported (ORs and HRs ≤1 indicate a beneficial effect). The median follow-up time was 67 months (interquartile range 45.5, range 0-129 months). Spearman's rho was used to estimate intraobserver agreement. Binary logistic regression was performed to analyze the association of risk factors with WMLs. Cox regression proportional hazards analysis was used to study the effect of different factors on survival. Results: WML severity could be assessed with a substantial intraobserver agreement (Spearman's rho 0.843, p < 0.0001). Only age (OR 1.10, 95% CI 1.06-1.15; p < 0.0001 per year), degree of ipsilateral ICA stenosis (OR 2.22, 95% CI 1.08-4.55; p < 0.05 per stenosis grade) and indication category (OR 1.63, 95% CI 1.19-2.24; p < 0.01 per category) remained independently associated with WMLs. Age (HR 1.04, 95% CI 1.01-1.08; p < 0.05 per year), diabetes (HR 1.59, 95% CI 1.01-2.49; p < 0.05), peripheral arterial disease (HR 2.47, 95% CI 1.46-4.15; p < 0.01), degree of ipsilateral ICA stenosis (HR 2.56, 95% CI 1.12-5.87; p < 0.05 per stenosis grade) and WMLs (HR 3.83, 95% CI 1.17-12.5; p < 0.05) remained independently associated with increased long-term mortality. Conclusions: WMLs in a preoperative CT scan provide a substantially reliable estimate of postoperative long-term survival of carotid endarterectomy patients independent of currently used criteria, i.e. cardiovascular risk factors, indication category and degree of ipsilateral ICA stenosis.

“…Our finding of an association of age with WML severity is in line with previous findings [20,29]. In the present study, the previous association of AHT with WMLs [20,29,30] was not replicated, which may be due to heterogeneity of the definition of hypertension including those with diagnosed hypertension under control and those without response.…”

Section: Discussionsupporting

confidence: 90%

“…In the present study, the previous association of AHT with WMLs [20,29,30] was not replicated, which may be due to heterogeneity of the definition of hypertension including those with diagnosed hypertension under control and those without response. Both the frequency of dyslipidemia and smoking decreased with increasing WML severity, in line with a previous study [20].…”

Section: Discussioncontrasting

confidence: 75%

Preoperative White Matter Lesions Are Independent Predictors of Long-Term Survival after Internal Carotid Endarterectomy

¹

,

²

,

³

et al. 2014

Cerebrovasc Dis Extra

View full text Add to dashboard Cite

Background: Cerebral white matter lesions (WMLs) predict long-term survival of conservatively treated acute stroke patients with etiology other than carotid stenosis. In carotid endarterectomy patients, WMLs are associated with severe carotid stenosis and unstable plaques, with the risk of perioperative complications and with increased 30-day perioperative risk of death. However, no data exist on their effect on postoperative long-term survival, a factor important when considering the net benefit from carotid endarterectomy. Whether this effect is independent of classical risk factors and indications for surgery is not known either. We hypothesized that WMLs could be evaluated from preoperative routine computed tomography (CT) scans and are predictors of postoperative survival, independent of classical cardiovascular risk factors, indication category and degree of carotid stenosis. Methods: A total of 353 of 481 (73.4%) consecutive patients subjected to carotid endarterectomy due to different indications, i.e. asymptomatic stenosis (n = 28, 7.9%), amaurosis fugax (n = 52, 14.7%), transient ischemic attack (n = 135, 38.2%) or ischemic stroke (n = 138, 39.1%), from prospective vascular registries during the years 2001-2010 with digital preoperative CT scans, were included in the study. WMLs were rated by a radiologist (Wahlund criteria) in a blinded fashion. Internal carotid artery (ICA) stenoses were angiographically graded (<50, 50-69, 70-99 and 100%). Odds ratios (ORs) and hazard ratios (HRs) are reported (ORs and HRs ≤1 indicate a beneficial effect). The median follow-up time was 67 months (interquartile range 45.5, range 0-129 months). Spearman's rho was used to estimate intraobserver agreement. Binary logistic regression was performed to analyze the association of risk factors with WMLs. Cox regression proportional hazards analysis was used to study the effect of different factors on survival. Results: WML severity could be assessed with a substantial intraobserver agreement (Spearman's rho 0.843, p < 0.0001). Only age (OR 1.10, 95% CI 1.06-1.15; p < 0.0001 per year), degree of ipsilateral ICA stenosis (OR 2.22, 95% CI 1.08-4.55; p < 0.05 per stenosis grade) and indication category (OR 1.63, 95% CI 1.19-2.24; p < 0.01 per category) remained independently associated with WMLs. Age (HR 1.04, 95% CI 1.01-1.08; p < 0.05 per year), diabetes (HR 1.59, 95% CI 1.01-2.49; p < 0.05), peripheral arterial disease (HR 2.47, 95% CI 1.46-4.15; p < 0.01), degree of ipsilateral ICA stenosis (HR 2.56, 95% CI 1.12-5.87; p < 0.05 per stenosis grade) and WMLs (HR 3.83, 95% CI 1.17-12.5; p < 0.05) remained independently associated with increased long-term mortality. Conclusions: WMLs in a preoperative CT scan provide a substantially reliable estimate of postoperative long-term survival of carotid endarterectomy patients independent of currently used criteria, i.e. cardiovascular risk factors, indication category and degree of ipsilateral ICA stenosis.

“…[1] Although LAA commonly coexists with cerebral SVD and shares many risk factors with SVD, [2–5] these two entities of cerebral vessel disease are thought to had different pathophysiologic mechanisms. [6, 7] Furthermore, the clinical impact of SVD on stroke recurrence in patients with LAA has not been well investigated.…”

Section: Introductionmentioning

confidence: 99%

The presence and severity of cerebral small vessel disease increases the frequency of stroke in a cohort of patients with large artery occlusive disease

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²

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³

et al. 2017

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BackgroundCerebral small vessel disease (SVD) commonly coexists with large artery atherosclerosis (LAA).AimWe evaluate the effect of SVD on stroke recurrence in patients for ischemic stroke with LAA.MethodsWe consecutively collected first-ever ischemic stroke patients who were classified as LAA mechanism between Jan 2010 and Dec 2013. Univariate and multivariate Cox analyses were performed to evaluate the association between the 2-year recurrence and demographic, clinical, and radiological factors. To evaluate the impact of SVD and its components on recurrent stroke, we used the Kaplan-Meier analysis. SVD was defined as the presence of severe white matter hyperintensity (WMH) or old lacunar infarction (OLI) or cerebral microbleeds (CMB). We also compared frequency and burden of SVD among recurrent stroke groups with different mechanisms.ResultsAmong a total of 956 participants, 92 patients had recurrent events. Recurrence group showed a higher frequency of severe WMH, OLI, asymptomatic territorial infarction, and severe stenosis on the relevant vessel in multivariate analysis. The impact of SVD and its components on recurrent stroke was significant in any ischemic recurrent stroke, and the presence of SVD was continuously important in stroke recurrence regardless of its mechanism, including recurrent LAA stroke, recurrent small vessel occlusion stroke, and even recurrent cardioembolic stroke. Additionally, the recurrence rate increased in dose-response manner with the increased number of SVD components.ConclusionsCerebral SVD is associated with recurrent stroke in patients with LAA. Additionally, it may affect any mechanisms of recurrent stroke and even with a dose response manner.

“…Although some studies 10–12 have suggested that patients with ICAS may be particularly prone to having coexistent SVD, there are limited data on the frequency and risk factors for coexistent SVD and the effect of SVD on stroke recurrence in patients with ICAS who receive medical treatment. The Stenting and Aggressive Medical Management for Preventing Recurrent Stroke in Intracranial Stenosis (SAMMPRIS) trial 13,14 provided a unique opportunity to investigate these associations.…”

Section: Introductionmentioning

confidence: 99%

Frequency, Risk Factors, and Outcome of Coexistent Small Vessel Disease and Intracranial Arterial Stenosis

¹

,

²

,

³

et al. 2016

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IMPORTANCE Intracranial arterial stenosis (ICAS) and small vessel disease (SVD) may coexist. There are limited data on the frequency and risk factors for coexistent SVD and the effect of SVD on stroke recurrence in patients receiving medical treatment for ICAS.OBJECTIVE To investigate the frequency and risk factors for SVD and the effect of SVD on stroke recurrence in patients with ICAS. DESIGN, SETTING, AND PARTICIPANTSA post hoc analysis of the Stenting and Aggressive Medical Management for Preventing Recurrent Stroke in Intracranial Stenosis (SAMMPRIS) study, a prospective, multicenter clinical trial. Among 451 participants, 313 (69.4%) had baseline brain magnetic resonance imaging scans read centrally for SVD that was defined by any of the following: old lacunar infarction, grade 2 to 3 on the Fazekas scale (for high-grade white matter hyperintensities), or microbleeds. Patient enrollment in SAMMPRIS began November 25, 2008, and follow-up ended on April 30, 2013. Data analysis for the present study was performed from May 13, 2014, to July 29, 2015. MAIN OUTCOMES AND MEASURESRisk factors in patients with vs without SVD and the association between SVD and other baseline risk factors with any ischemic stroke and ischemic stroke in the territory of the stenotic artery determined using proportional hazards regression. RESULTSOf 313 patients, 155 individuals (49.5%) had SVD noted on baseline magnetic resonance imaging. Variables that were significantly higher in patients with SVD, reported as mean (SD), included age, 63.5 (10.5) years (P < .001), systolic blood pressure, 149 (22) mm Hg (P < .001), glucose level, 130 (50) mg/dL (P = .03), and lower Montreal Cognitive Assessment scores (median, Ն24 [interquartile range, 20-26]; P = .02).Other significant variables were the number of patients with diabetes mellitus (88 of 155 [56.8%]; P = .003), coronary artery disease (46 [29.7%]; P = .004), stroke before the qualifying event (59 [38.1%]; P < .001), old infarct in the territory of the stenotic intracranial artery (88 [56.8%]; P < .001), and receiving antithrombotic therapy at the time of the qualifying event (109 [70.3%]; P = .005). The association between SVD and any ischemic stroke was nearly significant in the direction of a higher risk (18 [23.7%]); P = .07) for patients with SVD. On bivariate analysis, SVD was not associated with an increased risk on multivariable analyses (hazard ratio, 1.7 [95% CI, 0.8-3.8]; P = .20). In addition, SVD was not associated with an increased risk of stroke in the territory on either bivariate or multivariable analyses. CONCLUSIONS AND RELEVANCEAlthough SVD is common in patients with ICAS, the presence of SVD on baseline magnetic resonance imaging is not independently associated with an increased risk of stroke in patients with ICAS. TRIAL REGISTRATION clinicaltrials.gov Identifier NCT00576693

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