RESUMO
BACKGROUND AND PURPOSE: Lacunes of presumed vascular origin are perceived as biomarkers of cerebral small vessel disease (cSVD), although they may also be related to other pathogenetic mechanisms. We aimed to assess whether lacunes are more often associated with intracranial artery stenosis (IAS) than with white matter hyperintensities (WMH) of presumed vascular origin (a biomarker of cSVD) in older adults. METHODS: This study included 585 individuals aged ≥60 years living in rural Ecuador. Logistic regression models were fitted to assess the strength of the association between IAS or moderate-to-severe WHM on one side, and lacunes on the other. Mediation analysis was used to estimate the percentage of the effect of IAS on lacunes that was mediated by WMH. RESULTS: Lacunes were noticed in 62 (11%) individuals, IAS in 39 (7%), and moderate-to-severe WMH in 169 (29%). Fourteen of 39 individuals (36%) with IAS had lacunes, which corresponded to the territory of the stenotic artery in 50% of cases. Lacunes have a larger association with IAS than with moderate-to-severe WMH. The estimated prevalence rate of lacunes independently of any confounder was 10.6% (95% C.I.: 8.3-12.9%), which increased to 22.2% in subjects with IAS, but only to 16.4% among those with moderate-to-severe WMH. Only 24.5% of the effect of IAS on lacunes was mediated by WMH. CONCLUSION: Lacunes are more often associated with IAS than with WMH at the population level. Neuroimaging investigation of the intracranial vasculature in individuals with lacunes will provide informed-based decisions for secondary stroke prevention.
Assuntos
Doenças de Pequenos Vasos Cerebrais , Acidente Vascular Cerebral , Substância Branca , Idoso , Doenças de Pequenos Vasos Cerebrais/epidemiologia , Humanos , Imageamento por Ressonância Magnética/métodos , Neuroimagem , Acidente Vascular Cerebral/complicações , Substância Branca/patologiaRESUMO
OBJECTIVE: To determine whether the total small vessel disease (SVD) score adds information to the prediction of stroke outcome compared to validated predictors, we tested different predictive models of outcome in patients with stroke. METHODS: White matter hyperintensity, lacunes, perivascular spaces, microbleeds, and atrophy were quantified in 2 prospective datasets of 428 and 197 patients with first-ever stroke, using MRI collected 24 to 72 hours after stroke onset. Functional, cognitive, and psychological status were assessed at the 3- to 6-month follow-up. The predictive accuracy (in terms of calibration and discrimination) of age, baseline NIH Stroke Scale score (NIHSS), and infarct volume was quantified (model 1) on dataset 1, the total SVD score was added (model 2), and the improvement in predictive accuracy was evaluated. These 2 models were also developed in dataset 2 for replication. Finally, in model 3, the MRI features of cerebral SVD were included rather than the total SVD score. RESULTS: Model 1 showed excellent performance for discriminating poor vs good functional outcomes (area under the curve [AUC] 0.915), and fair performance for identifying cognitively impaired and depressed patients (AUCs 0.750 and 0.688, respectively). A higher SVD score was associated with a poorer outcome (odds ratio 1.30 [1.07-1.58], p = 0.0090 at best for functional outcome). However, adding the total SVD score (model 2) or individual MRI features (model 3) did not improve the prediction over model 1. Results for dataset 2 were similar. CONCLUSIONS: Cerebral SVD was independently associated with functional, cognitive, and psychological outcomes, but had no clinically relevant added value to predict the individual outcomes of patients when compared to the usual predictors, such as age and baseline NIHSS.
Assuntos
Doenças de Pequenos Vasos Cerebrais/diagnóstico por imagem , Doenças de Pequenos Vasos Cerebrais/epidemiologia , Imageamento por Ressonância Magnética/métodos , Acidente Vascular Cerebral/diagnóstico por imagem , Acidente Vascular Cerebral/epidemiologia , Idoso , Idoso de 80 Anos ou mais , Doenças de Pequenos Vasos Cerebrais/psicologia , Bases de Dados Factuais/tendências , Feminino , Seguimentos , Humanos , Imageamento por Ressonância Magnética/normas , Masculino , Pessoa de Meia-Idade , Valor Preditivo dos Testes , Acidente Vascular Cerebral/psicologia , Resultado do TratamentoRESUMO
PURPOSE: Cerebral small vessel disease (cSVD) has been overlooked in remote settings. In this study, we aimed to assess the burden of neuroimaging biomarkers of cSVD and its association with risk factors in community-dwelling older adults residing in rural Ecuador. METHODS: Brain MRIs were performed in 590 individuals aged ≥60 years living in three neighboring rural villages. MRI readings focused on white matter hyperintensities (WMH) of presumed vascular origin, deep cerebral microbleeds (CMB), enlarged basal ganglia-perivascular spaces (BG-PVS), and lacunes of presumed vascular origin. Mixed effects models for binary outcomes were fitted using WMH as the dependent variable. RESULTS: The mean age of participants was 71.1 ± 8.5 years (57% women). Moderate-to-severe WMH were noticed in 172 individuals (29%), deep CMB in 49 (8%), >10 enlarged BG-PVS in 183 (31%), and lacunes in 67 (11%). All biomarkers of cSVD were associated with increasing age, lower levels of education, poor physical activity, and arterial hypertension. Neuroimaging evidence of cSVD was present in almost half of older adults living in remote settings. CONCLUSIONS: Prompt recognition of cSVD biomarkers and implementation of strategic interventions may prove cost-effective for reducing its burden in underserved communities.
Assuntos
Doenças de Pequenos Vasos Cerebrais , Vida Independente , Idoso , Doenças de Pequenos Vasos Cerebrais/diagnóstico por imagem , Doenças de Pequenos Vasos Cerebrais/epidemiologia , Equador , Feminino , Humanos , Imageamento por Ressonância Magnética , Masculino , Pessoa de Meia-Idade , NeuroimagemRESUMO
OBJECTIVE: Cerebral small vessel disease (cSVD) and large artery atherosclerosis (LAA) are related to different pathogenetic mechanisms. However, relationships between single biomarkers of cSVD and LAA affecting isolated vascular beds have been reported. Using the Atahualpa Project cohort, we aimed to assess the association between cSVD score categories and LAA burden in community-dwelling older adults. PATIENTS AND METHODS: Atahualpa individuals aged ≥60 years undergoing assessment of the cSVD score and LAA in the peripheral, carotid extracranial, and intracranial vascular beds (n = 333) were included. Multivariate models were fitted to assess independent associations between the cSVD score and LAA burden. RESULTS: The cSVD score was 0 points in 62 % individuals, 1 point in 19 %, 2 points in 13 %, and 3-4 points in 7 %. LAA involved the extracranial carotid bed in 43 % individuals, the intracranial bed in 36 %, and the peripheral bed in 20 %. One vascular bed was involved in 111 (33 %) individuals, two beds in 75 (23 %), and three beds in 23 (7 %). The remaining 124 (37 %) had no atherosclerosis. Ordinal logistic regression models showed progressively greater associations between higher categories of cSVD score and the odds of having more beds involved with LAA. Multinomial logistic regression models showed associations between categories of cSVD score and LAA burden, but only when two or three vascular beds were involved. CONCLUSION: This study demonstrates robust associations between the cSVD score and LAA, which become evident at the upper end of the spectrum of cSVD score (3-4 points) and LAA burden (2-3 vascular beds involved).
Assuntos
Doenças de Pequenos Vasos Cerebrais/diagnóstico por imagem , Doenças de Pequenos Vasos Cerebrais/epidemiologia , Arteriosclerose Intracraniana/diagnóstico por imagem , Arteriosclerose Intracraniana/epidemiologia , Idoso , Idoso de 80 Anos ou mais , Artérias Carótidas/diagnóstico por imagem , Doenças das Artérias Carótidas/diagnóstico por imagem , Doenças das Artérias Carótidas/epidemiologia , Infarto Cerebral/diagnóstico por imagem , Infarto Cerebral/epidemiologia , Circulação Cerebrovascular , Estudos de Coortes , Efeitos Psicossociais da Doença , Equador/epidemiologia , Feminino , Inquéritos Epidemiológicos , Humanos , Vida Independente , Masculino , Pessoa de Meia-Idade , Modelos Estatísticos , Fatores de Risco , UltrassonografiaRESUMO
BACKGROUND: Evidence of the relationship between periodic limb movements during sleep (PLMS) and cerebral small vessel disease (cSVD) is limited and inconsistent. Here, we aimed to assess the independent association between PLMS and the different neuroimaging signatures of cSVD. METHODS: Atahualpa residents aged more than or equal to 60 years enrolled in the Atahualpa Project undergoing polysomnography and MRI with time intervals less than or equal to 6 months were included. MRI readings focused on white matter hyperintensities (WMH) of presumed vascular origin, deep cerebral microbleeds (CMB), silent lacunar infarcts (LI), and more than 10 enlarged basal ganglia-perivascular spaces (BG-PVS). Data from single-night polysomnograms were interpreted according to recommendations of the American Academy of Sleep Medicine. Associations between the PLMS index and neuroimaging signatures of cSVD (as dependent variables) were assessed by means of logistic regression models, adjusted for relevant confounders. RESULTS: A total of 146 individuals (mean age: 71.4 ± 7.5 years; 64% women) were included. A PLMS index more than or equal to 15 per hour were noted in 48 (33%) participants. Moderate-to-severe WMH were present in 33 individuals (23%), deep CMB in 9 (6%), silent LI in 16 (11%), and more than 10 BG-PVS in 44 (30%). In univariate analyses, silent LI (P = .035) and the presence of more than 10 enlarged BG-PVS (P = .034) were significantly higher among participants with a PLMS index more than or equal to 15 per hour. However, fully-adjusted multivariate models showed no significant association between PLMS index more than or equal to 15 per hour and any of the neuroimaging signatures of cSVD. CONCLUSIONS: This study shows no independent association between the PLMS index and neuroimaging signatures of cSVD in stroke-free community-dwelling older adults.
Assuntos
Doenças de Pequenos Vasos Cerebrais/diagnóstico por imagem , Vida Independente , Extremidade Inferior/inervação , Imageamento por Ressonância Magnética , Movimento , Neuroimagem/métodos , Síndrome da Mioclonia Noturna/fisiopatologia , Sono , Idoso , Idoso de 80 Anos ou mais , Doenças de Pequenos Vasos Cerebrais/epidemiologia , Doenças de Pequenos Vasos Cerebrais/fisiopatologia , Equador/epidemiologia , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Síndrome da Mioclonia Noturna/diagnóstico , Síndrome da Mioclonia Noturna/epidemiologia , Polissonografia , Valor Preditivo dos Testes , Medição de Risco , Fatores de Risco , Saúde da População RuralRESUMO
BACKGROUND: Wake-up stroke (WUS) are strokes that are noted upon awakening in patients previously going to bed in a normal state of health. The role of sleep abnormalities in WUS is uncertain. The objective was to determine clinical characteristics, respiratory abnormalities during sleep and outcomes in patients with WUS versus non-WUS. METHODS: At baseline, patients with ischemic stroke were examined clinically and with a portable sleep recorder. Apnea-Hypopnea Index greater than or equal to 20 defined a cut-off severity index. At follow-up (3 and 12-months), patients were re-evaluated clinically and with questionnaires: Epworth Sleepiness Scale, Modified Rankin (MR) and Modified Barthel Index Results: Among all (Nâ¯=â¯102, 64% male), hypertension (73%), Type 2 diabetes (29.4), heart disease (16.7%), physical inactivity (69.6%), smoking (32.4%) and alcohol consumption (17.6) were found. Apnea-Hypopnea Index (AHI) greater than 5 (92.9%), AHI greater than 15 (44.7%), AHI greater than or equal to 20 (35.3%) and AHI greater than 30 (11.8%) were registered. Cases with and without WUS did not differ regarding polygraphic findings. Long apneas (apnea duration > 20 s) was equally found in patients with WUS (23.1%) and non-WUS (23.7%). Type 2 diabetes mellitus (T2D) was independently associated with WUS (ORâ¯=â¯2.76; CI: 1.10-6.05; Pâ¯=â¯.03). Prospectively, symptom severity was not different between WUS and non-WUS. Overall, patients with OSA (IAH≥20) evolved with worse functional performance (MR, Pâ¯=â¯.02). CONCLUSIONS: Wake-up stroke occurred in approximately 1 of 3 of cases. Irrespective of WUS, half of the patients had moderate to severe sleep apnea; those with OSA (AHI≥ 20) evolved with worse functional performance after 1 year. WUS was associated with TDM reinforcing a relationship with cerebral small vessel disease.
Assuntos
Isquemia Encefálica/fisiopatologia , Pulmão/fisiopatologia , Respiração , Apneia Obstrutiva do Sono/fisiopatologia , Sono , Acidente Vascular Cerebral/fisiopatologia , Adulto , Idoso , Idoso de 80 Anos ou mais , Isquemia Encefálica/diagnóstico , Isquemia Encefálica/epidemiologia , Brasil/epidemiologia , Doenças de Pequenos Vasos Cerebrais/epidemiologia , Comorbidade , Diabetes Mellitus/epidemiologia , Avaliação da Deficiência , Feminino , Nível de Saúde , Humanos , Estilo de Vida , Estudos Longitudinais , Masculino , Pessoa de Meia-Idade , Prognóstico , Estudos Prospectivos , Fatores de Risco , Apneia Obstrutiva do Sono/diagnóstico , Apneia Obstrutiva do Sono/epidemiologia , Acidente Vascular Cerebral/diagnóstico , Acidente Vascular Cerebral/epidemiologia , Fatores de TempoRESUMO
Pineal gland calcification (PGC) has been associated with low melatonin production, a hormone with anti-oxidant, anti-inflammatory, and neuro-protective effects. Therefore, melatonin deficiency may play a role in the development of cerebral small vessel disease (cSVD), a condition that is partly related to upregulation of oxidative and inflammatory mechanisms leading to endothelial dysfunction, breakdown of the blood-brain barrier, and impaired interstitial fluid drainage. In this study, the association between PGC (a surrogate for melatonin deficiency) and white matter hyperintensities (WMHs) of presumed vascular origin (a biomarker of cSVD) was assessed in Atahualpa cohort individuals aged ≥60 years undergoing head CT and brain MRI. PGC was rated as none-to-mild and moderate-to-severe. WMHs were classified according to the modified Fazekas scale. A logistic regression model was fitted to assess the independent association between moderate-to-severe PGC and WMHs. Inverse probability of exposure weighting was used to estimate the effect of PGC on WMH. Of 373 individuals, 96 (26%) had moderate-to-severe PGC and 86 (23%) had moderate-to-severe WMHs. Moderate-to-severe PGC and WMH were independently associated in a fully-adjusted logistic regression model (OR: 2.21; 95% C.I.: 1.19-4.11; p = 0.012). Inverse probability of exposure weighting showed an estimate for the proportion of moderate-to-severe WMH among those with none-to-mild PGC of 20.5%, and the exposure-effect was 13.2% higher among those with moderate-to-severe PGC (ß: 0.132; 95% C.I: 0.036-0.229; p = 0.007). The association found in this study provides grounds for further evaluation of the role of melatonin deficiency in cSVD development.
Assuntos
Calcinose/diagnóstico por imagem , Doenças de Pequenos Vasos Cerebrais/diagnóstico por imagem , Glândula Pineal/diagnóstico por imagem , Vigilância da População , Substância Branca/diagnóstico por imagem , Idoso , Idoso de 80 Anos ou mais , Calcinose/epidemiologia , Doenças de Pequenos Vasos Cerebrais/epidemiologia , Estudos de Coortes , Estudos Transversais , Equador/epidemiologia , Feminino , Humanos , Imageamento por Ressonância Magnética/métodos , Masculino , Pessoa de Meia-Idade , Vigilância da População/métodos , Estudos ProspectivosRESUMO
INTRODUCTION: Recent guidelines suggest that a blood pressure cutoff of 130/80 mmHg should be used to define arterial hypertension. This contrasts with the previously accepted cutoff of 140/90 mmHg. AIM: Using the Atahualpa Project cohort, we aimed to assess the cutoff that better correlates with signatures of cerebral small vessel disease (SVD), which are related to arterial hypertension. METHODS: Of 437 Atahualpa residents aged ≥ 60 years, 363 (83%) underwent brain MRI and blood pressure determinations. Using logistic regression models, we evaluated the association between SVD and the two different cutoffs, after adjusting for demographics and cardiovascular risk factors. Using receiver operator characteristics curve analysis, we calculated sensitivity, specificity, and the area under the curve for the predictive value of the two cutoffs for detecting signatures of SVD. RESULTS: A comparison between the old and new cutoffs showed no differences in the ability to predict subjects with white matter hyperintensities, deep cerebral microbleeds or basal ganglia perivascular spaces. However, the new cutoff improved the identification of individuals with lacunar infarctions, which went from no association using the old cutoff (p = 0.097) to a significant association using the new cutoff (p = 0.036). The new cutoff was more sensitive but less specific than the old cutoff for identifying signatures of cerebral SVD. Areas under the curve were non-significantly higher for the old than for the new cutoffs for all the lesions of interest. CONCLUSIONS: The new blood pressure cutoff is consistently more sensitive but less specific than the old cutoff for detecting signatures of cerebral SVD. The most striking effect of the new cutoff is the improvement in the identification of lacunar infarctions.
Assuntos
Pressão Arterial , Determinação da Pressão Arterial , Doenças de Pequenos Vasos Cerebrais/diagnóstico por imagem , Hipertensão/diagnóstico , Imageamento por Ressonância Magnética , Idoso , Idoso de 80 Anos ou mais , Área Sob a Curva , Determinação da Pressão Arterial/normas , Doenças de Pequenos Vasos Cerebrais/epidemiologia , Doenças de Pequenos Vasos Cerebrais/fisiopatologia , Distribuição de Qui-Quadrado , Estudos Transversais , Equador/epidemiologia , Feminino , Humanos , Hipertensão/epidemiologia , Hipertensão/fisiopatologia , Modelos Lineares , Modelos Logísticos , Masculino , Pessoa de Meia-Idade , Razão de Chances , Valor Preditivo dos Testes , Prognóstico , Curva ROC , Reprodutibilidade dos Testes , Fatores de RiscoRESUMO
BACKGROUND: Basilar artery (BA) dolichoectasia has been associated with cerebral small vessel disease (SVD). However, studies have focused on stroke patients, and results cannot be extrapolated to the population at large. In this study, we aimed to assess prevalence of BA dolichoectasia and its association with SVD in community-dwelling older adults living in rural Ecuador. METHODS: Atahualpa residents aged ≥60 years underwent brain magnetic resonance imaging and magnetic resonance angiography of intracranial vessels. Following Smoker's criteria, the mean BA diameter plus 2 standard deviation defined ectasia. In addition, a location lateral to the lateral margin of the clivus of dorsum sellae or a bifurcation at the third ventricle floor or higher defined dolichosis. Associations between BA abnormalities and imaging markers of SVD were assessed by the use of regression models adjusted for demographics and cardiovascular risk factors. RESULTS: Of 346 participants, 11 (3.2%) had ectasia, 40 (11.6%) had dolichosis, and 47 (13.6%) had dolichoectasia (ectasia, dolichosis, or both). BA diameter was only associated with severity of white matter hyperintensities (P = .038). Dolichosis was associated with deep cerebral microbleeds (P = .002) but not with white matter hyperintensities. Dolichoectasia was associated with both white matter hyperintensities (P = .031) and cerebral microbleeds (P = .001). There were no associations with lacunar infarcts or enlarged perivascular spaces in any model. CONCLUSIONS: Prevalence of BA dolichoectasia in this rural setting is similar to that reported in other populations. Associations with imaging markers of SVD differ according to whether the subject has ectasia or dolichosis.
Assuntos
Doenças de Pequenos Vasos Cerebrais/epidemiologia , Vida Independente , Insuficiência Vertebrobasilar/epidemiologia , Fatores Etários , Idoso , Angiografia Cerebral/métodos , Doenças de Pequenos Vasos Cerebrais/diagnóstico por imagem , Estudos Transversais , Dilatação Patológica , Equador/epidemiologia , Feminino , Humanos , Hemorragias Intracranianas/diagnóstico por imagem , Hemorragias Intracranianas/epidemiologia , Leucoencefalopatias/diagnóstico por imagem , Leucoencefalopatias/epidemiologia , Angiografia por Ressonância Magnética , Masculino , Pessoa de Meia-Idade , Prevalência , Saúde da População Rural , Acidente Vascular Cerebral Lacunar/diagnóstico por imagem , Acidente Vascular Cerebral Lacunar/epidemiologia , Insuficiência Vertebrobasilar/diagnóstico por imagemRESUMO
BACKGROUND: Studies looking for an association between incompleteness of the Circle of Willis (CoW) and small vessel disease (SVD) markers are scarce and conflicting. We aimed to evaluate this association in an unbiased population-based study conducted in Atahualpa (rural Ecuador). METHODS: Atahualpa residents 60 years of age or more were identified during a door-to-door survey and invited to undergo magnetic resonance imaging for identification of SVD markers, including white matter hyperintensities (WMHs), strokes, and deep microbleeds. Magnetic resonance imaging (MRA) was used for classifying the CoW according to the presence or absence of one A1 segment of the anterior cerebral artery or one or both P1 segments of posterior cerebral arteries. RESULTS: Of 311 eligible persons, 258 were enrolled. Mean age was 70 ± 8 years, 59% were women, and 74% had a poor cardiovascular health (CVH) status. Of these, 172 patients (67%) had WMH, 40 patients (16%) had SVD-related strokes, and 23 patients (9%) had deep microbleeds. MRA revealed a complete CoW in 157 persons (61%). Persons with SVD markers were older than those without markers (P < .0001). A poor CVH status was noted in 79% of persons with at least 1 SVD marker and in 65% of those with no markers (P = .02). Logistic regression models showed no association of incompleteness of the CoW with any marker of SVD-alone or in combination-after adjusting for age, sex, and CVH status. CONCLUSIONS: Lack of association between incompleteness of CoW and SVD markers suggest that genetically determined variants in the intracranial vasculature are not responsible for the high prevalence of SVD among native South American populations.