Association of Dental Infections with Intracranial Atherosclerotic Stenosis.

INTRODUCTION: Periodontal disease (PD) and dental caries are oral infections leading to tooth loss that are associated with atherosclerosis and cerebrovascular disease. We assessed the hypothesis that PD and caries are associated with asymptomatic intracranial atherosclerosis (ICAS) in the Atherosclerosis Risk in Communities (ARIC) study. METHODS: Full-mouth clinical periodontal measurements (7 indices) collected at 6 sites per tooth from 6,155 subjects from the Dental Atherosclerosis Risk in Communities Study (DARIC) without prior stroke were used to differentiate seven PD stages (Periodontal Profile Class [PPC]-I to -VII) and dental caries on coronal dental surface (DS) and dental root surface (DRS). A stratified subset underwent 3D time-of-flight MR angiogram and 3D high isotropic-resolution black blood MRI. ICAS was graded according to the criteria established by the Warfarin-Aspirin Symptomatic Intracranial Disease (WASID) trial. We evaluated the relationship between PD stage and dental caries with asymptomatic ICAS, graded as no ICAS, <50% ICAS, and ≥50% ICAS. RESULTS: Among dentate subjects who underwent vascular imaging, 801 (70%) had no ICAS, 232 (20%) had <50% ICAS, and 112 (10%) had ≥50% ICAS. Compared to participants without gum disease (PPC-I), participants with mild-moderate tooth loss (PPC-VI), severe tooth loss (PPC-VII), and severe PD (PPC-IV) had higher odds of having <50% ICAS. Participants with extensive gingivitis (PPC-V) had significantly higher odds of having ≥50% ICAS. This association remained significant after adjusting for confounding variables: age, gender, race, hypertension, diabetes, dyslipidemia, 3-level education, and smoking status. There was no association between dental caries (DS and DRS) and ICAS <50% and ≥50%. CONCLUSION: We report significant associations between mild-moderate tooth loss, severe tooth loss, and severe PD with <50% ICAS as well as an association between extensive gingivitis and ≥50% ICAS. We did not find an association between dental caries and ICAS.

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.

MR Imaging Measures of Intracranial Atherosclerosis in a Population-based Study.

Purpose To implement a magnetic resonance (MR) imaging protocol to measure intracranial atherosclerotic disease (ICAD) in a population-based multicenter study and report examination and reader reliability of these MR imaging measurements and descriptive statistics representative of the general population. Materials and Methods This prospective study was approved by the institutional review boards and compliant with HIPAA. Atherosclerosis Risk in Communities (ARIC) study participants (n = 1980) underwent brain MR imaging from 2011 to 2013 at four ARIC sites. Imaging included three-dimensional black-blood MR imaging and time-of-flight MR angiography. One hundred two participants returned for repeat MR imaging to estimate examination and reader variability. Plaque presence according to vessel segment was recorded. Quantitative measurements included lumen size and degree of stenosis, wall and/or plaque thickness, area and volume, and normalized wall index for each vessel segment. Reliability was assessed with percentage agreement, κ statistics, and intraclass correlation coefficients. Results Of the 1980 participants, 1755 (mean age, 77.6 years; 1026 women [59%]; 1234 white [70%]) completed examinations with adequate to excellent image quality. The weighted ICAD prevalence was 34.4% (637 of 1755 participants) and was higher in men than women (38.5% [302 of 729 participants] vs 31.7% [335 of 1026 participants], respectively; P = .012) and in African Americans compared with whites (41.1% [215 of 518 participants] vs 32.4% [422 of 1234 participants], respectively; P = .002). Percentage agreement of plaque identification per participant was 87.0% (interreader estimate), 89.2% (intrareader estimate), and 89.9% (examination estimate). Examination and reader reliability ranged from fair to good (κ, 0.50-0.78) for plaque presence and from good to excellent (intraclass correlation coefficient, 0.69-0.99) for quantitative vessel wall measurements. Conclusion Vessel wall MR imaging is a reliable tool for identifying and measuring ICAD and provided insight into ICAD distribution across a U.S. community-based population. (©) RSNA, 2016 Online supplemental material is available for this article.

Cost-effectiveness analysis of intracranial stent placement versus contemporary medical management in patients with symptomatic intracranial artery stenosis.

BACKGROUND: Intracranial angioplasty and stent placement has been increasingly evaluated as a new method for treatment of symptomatic intracranial stenosis in select patients. The Food and Drug Administration (FDA) has approved intracranial stent treatment of symptomatic atherosclerotic intracranial lesions. PURPOSE: To determine the cost-effectiveness of intracranial artery stent placement compared with contemporary medical management for secondary stroke prevention among patients with symptomatic intracranial stenosis. METHODS: Clinical outcome data were obtained from the aspirin treatment arm of the Comparison of Warfarin and Aspirin for Symptomatic Intracranial Disease (WASID) trial (n = 280) and 12 case series (n = 216) of patients who underwent stent placement of symptomatic intracranial stenosis with comparable characteristics. Total cost of procedure and medical management-only was calculated using the rates of major stroke, minor stroke, or death in each group. All costs are expressed in 2010 US$. The quality-adjusted life-year (QALY) of each intervention strategy was estimated using the frequency of the outcomes of major and minor stroke, death, and baseline health. An incremental cost-effectiveness ratio (ICER) was formulated for a 1-year period. RESULTS: The total rate of stroke at one year was 10.2% (6.1-14.2%) and the rate of all-cause mortality was 3.7% (1.2-6.2%) in the stent group. The corresponding annualized rates of stroke and all-cause mortality in the medical management-only group were 15% (10.8-19.2%) and 2.4% (0.6-4.2%), respectively. The calculated net costs at one year for intracranial stent placement and contemporary medical management were US$16,898 and US$3,468, respectively. Overall, QALYs for the two groups were 0.82 and 0.81 (in a range of 0 to 0.89 corresponding to death and baseline health), respectively. The cost per QALY gained after intracranial stent placement and contemporary medical therapy was US$20,542 and US$4,265, respectively. The corresponding ICER for stent versus medical treatment alone was US$1,416,268. CONCLUSION: The reduced risk of stroke following intracranial stent placement is offset by significantly higher procedure-associated net costs. Select procedures in patients with symptomatic stenosis of 70% or greater are more likely to be cost-effective.

Epidemiological and clinical features of moyamoya disease in the USA.

BACKGROUND: An increasing number of cases of Moyamoya disease have been reported in the Japanese and US literature. We performed this study to quantify the rise in the prevalence of Moyamoya disease and to study the unique epidemiological and clinical features in the USA that may explain a change in incidence. METHODS: We analyzed data derived from patients entered in the Nationwide Inpatient Sample between 2005 and 2008, using ICD-9 codes for Moyamoya disease. Data including patient age, gender, ethnicity, secondary diagnosis, medical complications, and hospital costs were obtained. RESULTS: From 2005 to 2008 in the USA, there were an estimated 7,473 patients admitted with a primary or secondary diagnosis of Moyamoya disease. Patients admitted with Moyamoya disease were most frequently women and Caucasian. Overall, ischemic stroke was the most common reason for admission. Hemorrhagic stroke was more frequent in adults compared with children, 18.1 versus 1.5% (p < 0.05). CONCLUSION: The number of patients identified and admitted with Moyamoya disease has risen dramatically in the last decade. This study can lead to a better understanding of the disease pattern and healthcare consequences in the USA and suggests that pathophysiologic differences in Moyamoya disease may exist.

Prevalence and characteristics of concurrent down syndrome in patients with moyamoya disease.

BACKGROUND: An association between moyamoya disease and Down syndrome appears to exist on the basis of reported anecdotal cases in the literature. OBJECTIVE: To determine the prevalence of Down syndrome associated with moyamoya disease in inpatients and to identify the demographic and clinical features of moyamoya disease that may be unique when associated with Down syndrome. METHODS: In this observational study, we analyzed data from the Nationwide Inpatient Sample between 2002 and 2009 using International Classification of Diseases codes for moyamoya disease and Down syndrome for patient identification. Data including patient age, sex, race/ethnicity, secondary diagnosis, procedures, hospital costs, and patient outcomes were obtained. RESULTS: From 2002 to 2009, an estimated 518 patients (mean ± SD age, 16.2 ± 1.68 years) with coexisting moyamoya disease and Down syndrome were admitted. The estimated prevalence was 3.8% (3760 per 100,000) among patients admitted with moyamoya disease and 9.5% (9540 per 100,000) among moyamoya patients < 15 years of age. Patients admitted with moyamoya disease and Down syndrome were most frequently white and Hispanic (P = .02). They were more likely to present with ischemic stroke and less commonly with hemorrhagic stroke (15.3% and 2.7%, respectively; P < .05). CONCLUSION: This is the first study to estimate the prevalence of Down syndrome in patients with moyamoya disease. The 26-fold-greater prevalence of Down syndrome in patients with coexisting moyamoya disease compared with the prevalence of Down syndrome among live births (145 per 100,000) highlights the need for a better understanding of the common pathophysiology of the 2 conditions.

Intravenous Thrombolysis in Expanded Time Window (3-4.5 hours) in General Practice with Concurrent Availability of Endovascular Treatment.

INTRODUCTION: A randomized double-blind trial (ECASS III) demonstrated that intravenous (IV) recombinant tissue plasminogen activator (rt-PA) administered between 3 and 4.5 hrs after the onset of symptoms significantly improved clinical outcomes in patients with acute ischemic stroke. In May 2009, the American Stroke Association guidelines recommended the use of IV rt-PA for patients presenting within 3 and 4.5 hrs after symptom onset. OBJECTIVE: To determine the rate of patients treated with IV rt-PA within the 3- and 4.5-hr time window and associated comparative outcomes in general practice. METHODS: We retrospectively reviewed all patients who were treated with IV rt-PA at two comprehensive stroke centers from September 1, 2008 to July 31, 2010 and identified a total of 98 patients. In addition, we identified patients who arrived to the ED of those centers within 2.5 to 4 hrs of symptom onset between January 1, 2007 and June 30, 2010 and received only endovascular treatment. We compared the rates of favorable outcome (determined by using modified Rankin scale 0-2 at discharge and 3-month follow-up), and National Institutes of Health Stroke Scale (NIHSS) score improvement by ≥ 4 points or 0 at discharge among patients treated with IV rt-PA within 3-4.5 hrs with those who received IV rt-PA within 0-3 hrs, and subsequently with patients presenting at similar time window treated only with endovascular treatment. RESULT: Out of the total 98 IV rt-PA treated patients, 84 of them were treated within 0-3 hrs, and 14 within the 3--4.5 hrs. Twelve patients received endovascular treatment only for the specified time window. Mean admission NIHSS score ± standard deviation (SD) was 11.90 ± 6.72, 8.57 ± 5.40, and 11.75 ± 8.06, for the 0--3, 3--4.5 hrs, and endovascular only treatment groups, respectively. Favorable clinical outcome at discharge (50% vs. 56%, p=0.77), 3 months (64% vs. 64%, p=1.0), and NIHSS score improvement (43% vs. 58%, p=0.38) were not different between those treated within 3-4.5 and 0-3 hrs time windows. There appeared to be a non-significantly higher rate of favorable outcomes at discharge (25% vs. 50%, p=0.24), and at 3 months (42% vs. 64%, p=0.43) among patients treated with IV rt-PA within 3-4.5 hrs compared with those treated with primary endovascular treatment. CONCLUSION: An additional 14% of patients received IV rt-PA because of treatment window expansion from 3 to 4.5 hrs. Outcomes were comparable to those treated within 3 hrs of symptom onset. The shift of those patients from primary endovascular treatment does not appear to adversely affect patient outcomes.

Neurointerventional procedural volume per hospital in United States: implications for comprehensive stroke center designation.

BACKGROUND AND PURPOSE: Availability of neurointerventional procedures is recommended as a necessary component of a comprehensive stroke center by various regulatory guidelines that also emphasize adequate procedural volumes. We studied the volumes of neurointerventional procedures performed in various hospitals across the United States with subsequent comparisons with rates of minimum procedural volumes recommended by various professional bodies or used in clinical trials to ensure adequate operator experience. METHODS: We reviewed the Nationwide Inpatient Sample database in the United States for the years 2005 to 2008. Using International Classification of Disease-Clinical Modification, 9th revision, and Medicare severity diagnosis-related group codes, we identified among hospitals that admit stroke patients those that met the minimum criteria for overall and individual procedural volumes specified in various guidelines. We then compared the characteristics between the high-volume hospitals that performed at least 100 cervicocerebral angiograms and met ≥1 other procedural criterion (n=79) and low-volume hospitals (n=958). RESULTS: Proportions of hospitals that met individual procedural volume criteria over the 4-year period according to procedure were: cervicocerebral angiography (7.0%-7.8%); endovascular acute ischemic stroke treatments (0.4%-2.6%); carotid angioplasty/stent placement (3.0%-5.3%); intracranial angioplasty/stent placement (0.3%-1.3%); and aneurysm embolization (1.3%-2.6%). There were significant trends for increasing numbers of all the endovascular procedures except intracranial angioplasty/stent placement over the course of 4 years. The high-volume hospitals were more likely to be urban teaching hospitals (70.9% versus 13.1%; P<0.001), had larger bed size (79.7% versus 26.9%; P<0.001), and had significantly higher rates of hemorrhagic stroke admissions and lower rates of transient ischemic attack admissions. Urban teaching location/status (OR, 8.92; CI, 4.3-18.2; P<0.001) and large bed size (OR, 4.40; CI, 2.0-9.5; P<0.001) remained as independent predictors of a high-volume hospital when adjusted for age, gender, risk factors, and stroke subtype. CONCLUSIONS: There are very few hospitals in the United States that meet all the neurointerventional procedural volume criteria for all endovascular procedures recommended to ensure adequate operator experience. Our results support the creation of specialized regional centers for ensuring adequate procedural volume within treating hospitals.

Regular egg consumption does not increase the risk of stroke and cardiovascular diseases.

BACKGROUND: We performed this study to examine the association between egg consumption and risk of cardiovascular diseases and mortality in a nationally representative cohort of 9734 adults aged 25 to 74 years. MATERIAL/METHODS: Egg consumption was categorized into no or less than 1 egg, 1 to 6 eggs, or greater than 6 eggs per week. Cox proportional hazards analysis was used to identify the relative risk (RR) of incident stroke, ischemic stroke, coronary artery disease and mortality over a 20-year follow-up in all participants and subsequently in diabetic participants. RESULTS: After adjusting for differences in age, gender, race, serum cholesterol level, body mass index, diabetes mellitus, systolic blood pressure, educational status and cigarette smoking, no significant difference was observed between persons who consumed greater than 6 eggs per week compared to those who consume none or less than 1 egg per week in regards to any stroke (RR, 0.9; 95% confidence interval (CI), 0.7 to 1.1), ischemic stroke (RR, 0.9; 95% CI, 0.7 to 1.1), or coronary artery disease (RR, 1.1; 95% CI, 0.9 to 1.3). In subgroup analysis among diabetics, consumption of greater than 6 eggs per week was associated with an increased risk of coronary artery disease (RR 2.0, 95% CI 1.0-3.8). CONCLUSIONS: Consumption of greater than 6 eggs per week (average of 1 egg or greater per day) does not increase the risk of stroke and ischemic stroke. The increased risk of coronary artery disease associated with higher egg consumption among diabetics warrants further investigations.

Free thyroxine index and risk of stroke: results from the National Health and Nutrition Examination Survey Follow-up Study.

BACKGROUND: The long-term risks of stroke associated with hypothyroidism and hyperthyroidism is unknown. We evaluated the long-term risk of stroke with hypothyroidism and hyperthyroidism compared with euthyroid status. MATERIAL/METHODS: We used the 20-year follow-up data for adults aged 25 to 74 years who participated in the First National Health and Nutrition Examination Survey Follow-up Study. Hypothyroidism or hyperthyroidism was diagnosed by free thyroxine index measurements at baseline evaluation and incident events were determined from hospital records and death certificates during follow-up. Relative risk (RR) of stroke, ischemic stroke, and intracerebral hemorrhage for each category of thyroid function were determined by Cox proportional hazards analysis after adjustment for potential confounding variables. RESULTS: A total of 5,269 participants (mean age 48+/-14 years; 2,379 men) were evaluated. Hypothyroidism and hyperthyroidism were diagnosed in 493 (9.4%) and 34 (0.7%) participants, respectively. After adjustment for covariates, a significantly higher RR for all strokes and for ischemic stroke was observed in participants with hypothyroidism (RR 1.6; 95% confidence interval (CI), 1.0-2.6 and RR 1.6, 95% CI, 1.0-2.7, respectively). Hyperthyroidism was not associated with an increased risk for stroke. CONCLUSIONS: An increased risk for stroke (particularly ischemic stroke) was observed in patients with hypothyroidism.