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BACKGROUND: Atherosclerotic disease of the aortic arch is found in 60 percent of patients 60 years of age or older who have had brain infarction. The aim of this study was to determine whether atherosclerotic plaques in the aortic arch are a risk factor for recurrent brain infarction and for vascular events in general (i.e., brain infarction, myocardial infarction, peripheral embolism, and death from vascular causes). METHODS: For a period of two to four years, we followed a cohort of 331 patients 60 years of age or older who were consecutively admitted to the hospital with brain infarction (a total of 788 person-years of follow up). All patients underwent transesophageal echocardiography to determine whether atherosclerotic plaques were present in the aortic arch proximal to the ostium of the left subclavian artery. The patients were divided into three groups according to the thickness of the wall of the aortic arch ( < 1 mm, 1 to 3.9 mm, and > or = 4 mm). RESULTS: The incidence of recurrent brain infarction was 11.9 per 100 person-years in patients with an aortic-wall thickness of > or = 4 mm, as compared with 3.5 per 100 person-years in patients with a wall thickness of 1 to 3.9 mm and 2.8 per 100 person-years in patients with a wall thickness of < 1 mm (P < 0.001). The overall incidence of vascular events was 26.0, 9.1, and 5.9 per 100 person-years of follow-up in the respective groups (P < 0.001). After adjustment for the presence of carotid stenosis, atrial fibrillation, peripheral arterial disease, and other risk factors, aortic plaques > or = 4 mm thick (including the thickness of the aortic wall) were found to be independent predictors of recurrent brain infarction (relative risk, 3.8; 95 percent confidence interval, 1.8 to 7.8; P = 0.0012) and of all vascular events (relative risk, 3.5; 95 percent confidence interval, 2.1 to 5.9; P < 0.001). CONCLUSIONS: Atherosclerotic plaques > or = 4 mm thick in the aortic arch are significant predictors of recurrent brain infarction and other vascular events.
The outcome of 703 patients who underwent surgery following aneurysmal subarachnoid hemorrhage were analyzed with regards to age, associated medical conditions, vasospasm and clinical status at the time of operation. Patients with Hunt and Hess grade I, II, and III had a 96%, 90% and 93% favorable (good and fair) outcome respectively. In contrast only 58% of patients with grade IV had the same result. The outcome was unfavorable in 13% of the patients who were older than 60 years of age and only in 9% of the patients between 30-59 years of age. All the patients younger than 30 years old had a good outcome. Associated medical condition increased the incidences of poor outcome (7% vs. 12%). Patients harboring vertebro basilar aneurysms had a poorer outcome, as opposed to those with aneurysms located in the anterior circulation (20% vs. 8%). The presence of angiographic vasospasm alone did not influence outcome. A proposed point value was given for each of the adverse factors and from this the optimal surgical time was determined for each individual patient. This concept of Risk Score Estimation approach may improve the management outcome of patients with ruptured intracranial aneurysms.
Associations between findings on cranial magnetic resonance imaging (MRI) and retinal photographs have been described mostly in middle-aged people. In the Cardiovascular Health Study, 1,717 elderly participants underwent MRI and retinal photography between 1991 and 1999. Associations were sought between MRI findings and four findings of retinal microvascular disease: retinopathy, focal arteriolar narrowing, arteriovenous nicking, and the arteriovenous ratio--the last based upon semiautomated measurements of arterioles and venules. After controlling for age and gender, the authors found associations between MRI findings and the smaller arteriovenous ratio (per standard deviation decrease): prevalent infarcts (odds ratio = 1.18, 95% confidence interval: 1.05, 1.34; p = 0.007), white matter grade (regression coefficient, 0.093; p = 0.011), incident infarct (odds ratio = 1.26, 95% confidence interval: 1.09, 1.46; p = 0.002), and worsening white matter grade (odds ratio = 1.12, 95% confidence interval: 0.98, 1.29; p = 0.09). Arteriovenous nicking was also associated with prevalent (odds ratio = 1.84, 95% confidence interval: 1.23, 2.76; p = 0.003) and incident (odds ratio = 1.84, 95% confidence interval: 1.15, 2.94; p = 0.011) infarcts. Adjustment for hypertension and diabetes had minimal effect. Evidence of small vessel disease in the retina increases the likelihood of finding it in the brain. Associations were less prominent in this elderly population than have been described in middle-aged people.
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Percutaneous transluminal angioplasty (PTA), an established treatment of arterial stenosis in coronary, renal, and other peripheral sites, is being applied to the cerebrovascular territory with greater frequency. Early results suggest that PTA may be safe and efficacious in the treatment of extracranial arterial stenosis secondary to atherosclerosis and fibromuscular dysplasia. PTA is also being used with promising results in treating symptomatic intracranial arterial stenosis from atherosclerosis. This review examines PTA in the treatment of cerebrovascular disease, current indications, and results.
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Cholesterol embolization to the abdominal viscera is common, but rare in the central nervous system. Fourteen cases of atheromatous embolization to the central nervous system were morphologically investigated. Among the 800 consecutive autopsy cases, 38 cases had atheromatous emboli in various organs. Cerebro-spinal infarction caused by atheromatous emboli was found in 11 cases. Infarction rate (11/14) was relatively higher than in other organs and 5 of these cases were thought to be due to direct injury to the erosive surface of the aorta; cardiac catheterization (2 cases), intra-aortic balloon pumping (2 cases), and extra-anatomical bypass graft operation (1 case). These 14 patients consisted of elderly patients (70.1 +/- 6.3 years old) usually associated with hypertension (78.6%) and diabetes mellitus (42.8%). Anatomically, aortic aneurysms were seen in 10 cases (71.4%), in which aortic arch aneurysm was seen in 6 cases. Hence, aortic mechanical procedure is of great importance for denuding atheromatous materials from erosive atherosclerosis to the central nervous system.
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Contrary to prevailing medical belief, dementia is generally not caused by arteriosclerosis of cerebral vessels. There may be, in fact, as many as 50 different causes. While the two major types of dementia, Alzheimer's disease and multi-infarct dementia, are irreversible, perhaps 20 per cent of dementias are secondary to treatable causes, and are reversible. The most important of these is the pseudodementia of depression, which can be easily missed without a high degree of suspicion. Tips on the differential diagnosis of Alzheimer's disease, multi-infarct dementia, and pseudodementia are discussed, as are other causes of dementia secondary to various diseases or therapy.
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A common C825T polymorphism in the gene GNB3, which encodes the beta 3 subunit of heterotrimeric G proteins, was identified in cell lines from patients with hypertension. The 825T allele is associated with increased intracellular signal transduction. Many population-based and case-control studies in different ethnicities have investigated an association between this polymorphism and hypertension, obesity, and atherosclerosis. A critical assessment of published studies suggests that 825T allele carriers have an increased risk for hypertension combined with features of the metabolic syndrome, such as dyslipidemia, hypercholesterolemia, insulin resistance, and obesity. It is anticipated that this polymorphism will be used in clinical practice to better characterize hypertension and for individualized treatment regimens.
PURPOSE: To investigate the prevalence of cervical and intracranial atherosclerosis and silent brain infarction in patients with coronary artery disease (CAD). METHODS: Cervical and intracranial atherosclerotic lesions on magnetic resonance angiography (MRA) and silent brain infarctions on magnetic resonance imaging (MRI) were investigated in comparison with the findings of coronary angiography in 133 consecutive patients with CAD. RESULTS: The mean severity scores of cervical and intracranial MRA lesions were significantly higher in the three-vessel CAD (0.40 and 0.53, respectively) than in the zero-vessel CAD group (0.04 and 0.11). The mean scores of the maximal size and multiplicity of MRI lesion were also significantly greater in the two-vessel (1.00 and 1.44) and three-vessel CAD (0.94 and 1.26) than in the zero-vessel CAD group (0.27 and 0.50). The incidence of MRA lesion was markedly higher in patients with brain MRI lesion than in those without (51.1 vs. 6.5%). CONCLUSIONS: Serious coronary artery lesions were commonly accompanied by latent atherosclerotic lesions in the cervical and intracranial arteries besides silent brain infarction in patients with CAD.
During the last few years, there has been emphasis on the role of the interatrial septum and the aortic arch atheroma in the genesis of stroke. The causal relationship of these disorders with stroke is still controversial because direct evidence may be lacking. The diagnosis is often presumed and based on indirect signs, i.e. by visualization of the interatrial septal or aortic arch abnormalities which are detectable by transesophageal echocardiography. The optimal therapeutic strategy including some more invasive treatments, such as surgery, is uncertain. In this article, we review the current knowledge concerning the interatrial septum and aortic arch disorders as risk factors for stroke and current therapeutic strategies.