Racial and Ethnic Disparities in Heart and Cerebrovascular Disease Deaths During the COVID-19 Pandemic in the United States.

BACKGROUND: Cardiovascular deaths increased during the early phase of the COVID-19 pandemic in the United States. However, it is unclear whether diverse racial/ethnic populations have experienced a disproportionate rise in heart disease and cerebrovascular disease deaths. METHODS: We used the National Center for Health Statistics to identify heart disease and cerebrovascular disease deaths for non-Hispanic White, non-Hispanic Black, non-Hispanic Asian, and Hispanic individuals from March to August 2020 (pandemic period), as well as for the corresponding months in 2019 (historical control). We determined the age- and sex-standardized deaths per million by race/ethnicity for each year. We then fit a modified Poisson model with robust SEs to compare change in deaths by race/ethnicity for each condition in 2020 versus 2019. RESULTS: There were a total of 339 076 heart disease and 76 767 cerebrovascular disease deaths from March through August 2020, compared with 321 218 and 72 190 deaths during the same months in 2019. Heart disease deaths increased during the pandemic in 2020, compared with the corresponding period in 2019, for non-Hispanic White (age-sex standardized deaths per million, 1234.2 versus 1208.7; risk ratio for death [RR], 1.02 [95% CI, 1.02-1.03]), non-Hispanic Black (1783.7 versus 1503.8; RR, 1.19 [95% CI, 1.17-1.20]), non-Hispanic Asian (685.7 versus 577.4; RR, 1.19 [95% CI, 1.15-1.22]), and Hispanic (968.5 versus 820.4; RR, 1.18 [95% CI, 1.16-1.20]) populations. Cerebrovascular disease deaths also increased for non-Hispanic White (268.7 versus 258.2; RR, 1.04 [95% CI, 1.03-1.05]), non-Hispanic Black (430.7 versus 379.7; RR, 1.13 [95% CI, 1.10-1.17]), non-Hispanic Asian (236.5 versus 207.4; RR, 1.15 [95% CI, 1.09-1.21]), and Hispanic (264.4 versus 235.9; RR, 1.12 [95% CI, 1.08-1.16]) populations. For both heart disease and cerebrovascular disease deaths, Black, Asian, and Hispanic populations experienced a larger relative increase in deaths than the non-Hispanic White population (interaction term, P<0.001). CONCLUSIONS: During the COVID-19 pandemic in the United States, Black, Hispanic, and Asian populations experienced a disproportionate rise in deaths caused by heart disease and cerebrovascular disease, suggesting that these groups have been most impacted by the indirect effects of the pandemic. Public health and policy strategies are needed to mitigate the short- and long-term adverse effects of the pandemic on the cardiovascular health of diverse populations.

An Assessment of the Relationship between Structural and Functional Imaging of Cerebrovascular Disease and Cognition-Related Fibers.

In order to assess the relationship between structural and functional imaging of cerebrovascular disease and cognition-related fibers, this paper chooses a total of 120 patients who underwent cerebral small vessel disease (CSVD) treatment at a designated hospital by this study from June 2013 to June 2018 and divides them into 3 groups according to the random number table method: vascular dementia (VaD) group, vascular cognitive impairment no dementia (VCIND) group, and noncognition impairment (NCI) group with 40 cases of patients in each group. Cognitive function measurement and imaging examination were performed for these 3 groups of patients, and the observation indicators of cognitive state examination (CSE), mental assessment scale (MAS), clock drawing test (CDT), adult intelligence scale (AIS), frontal assessment battery (FAB), verbal fluency test (VFT), trail making test (TMT), cognitive index (CI), white matter lesions (WML), third ventricle width (TVW), and frontal horn index (FHI) were tested, respectively. The results shows that the average scores of CSE, MAS, AIS, and VFT in the VaD and VCIND group are lower than those of the NCI group and the differences are statistically significant (P < 0.05); the average scores of FAB, TMT, and CI in the VaD group are higher than those of the VCIND group and the differences are also statistically significant (P < 0.05); the average scores of FHI and TVW in the VaD group are lower than those of the VCIND and NCI group with statistically significant differences (P < 0.05); the average scores of WML, CDT, and AIS in the VaD group are higher than those of the VCIND and NCI group with statistically significant differences (P < 0.05). Therefore, it is believed that the structural and functional imaging features of cerebrovascular disease are closely related to cognition-related fibers, and the incidence of white matter lesions is closely related to the degree of lesions and cognitive dysfunction of cerebral small vessel disease, in which a major risk factor for cognitive dysfunction in patients with small blood vessels is the severity of white matter lesions; brain imaging and neuropsychiatric function assessment can better understand the relationship between cerebrovascular disease and cognitive impairment. The results of this study provide a reference for the further research studies on the relationship between structural and functional imaging of cerebrovascular disease and cognition-related fibers.

Neuropathologic Correlates of White Matter Hyperintensities in a Community-Based Cohort of Older Adults.

BACKGROUND: The association of white matter hyperintensities (WMH) with age-related vascular and neurodegenerative pathologies remains incompletely understood. OBJECTIVE: The objective of this work was to elucidate the neuropathologic correlates of WMH in a large community-based cohort of older adults. METHODS: Cerebral hemispheres from 603 community-based older adults were imaged with MRI ex vivo. All participants underwent annual clinical evaluation, cognitive assessment, and neuropathologic examination. WMH burden was assessed using a modified Fazekas rating scale. Multiple ordinal logistic regression was used to test the association of WMH burden with an array of age-related neuropathologies, adjusting for demographics. Mixed effects models of cognition controlling for neuropathologies and demographics were used to determine whether WMH burden contributes to cognitive decline beyond measured pathologies. RESULTS: WMH burden in the whole group was associated with both vascular and Alzheimer's disease (AD) pathologies: arteriolosclerosis (p < 10-4), gross (p < 10-4), and microscopic infarcts (p = 0.04), and amyloid-ß plaques (p = 0.028). In non-demented participants (mild or no cognitive impairment) (N = 332), WMH burden was related to gross infarcts (p = 10-4) and arteriolosclerosis (p < 10-4), but not to AD pathology. Similarly, in those with no cognitive impairment (N = 178), WMH burden was related to gross infarcts (p = 8×10-4) and arteriolosclerosis (p = 0.014). WMH burden was associated with faster decline in perceptual speed in both the whole (p = 0.038) and non-demented (p = 0.006) groups. CONCLUSION: WMH burden has independent associations with vascular pathologies in older adults regardless of clinical status, and with AD pathology later in the progression of AD. Moreover, WMH burden may reflect additional tissue injury not captured with traditional neuropathologic indices.

Intracranial vascular pathology in two further patients with Floating-Harbor syndrome: Proposals for cerebrovascular disease risk management.

Floating-Harbor syndrome (FHS) is a rare, heritable disorder caused by variants in the SRCAP gene. Most individuals with FHS have characteristic facial features, short stature, and speech and language impairment. Although FHS has been likely under-diagnosed due to a combination of lack of recognition of the clinical phenotype and limited access to genomic testing, it is a rare condition with around 100 individuals reported in the medical literature. Case series have been biased towards younger individuals (vast majority <20 years of age) meaning that it has been challenging to provide accurate medical advice for affected individuals in adulthood. We report two young adults with FHS who presented with intracranial haemorrhage likely secondary to cerebrovascular aneurysms, with devastating consequences, making a total of four FHS patients reported with significant cerebrovascular abnormalities. Three of four patients had hypertension, at least one in conjunction with normal renal structure. We consider possible relationships between hypertension, renal pathology and aneurysms in the context of FHS, and consider mechanisms through which disruption of the SRCAP protein may lead to vascular pathology. We recommend that clinicians should have a low threshold to investigate symptoms suggestive of cerebrovascular disease in FHS. We advise that patients with FHS should have annual blood pressure monitoring from adolescence, renal ultrasound at diagnosis repeated in adulthood, and timely investigation of any neurological symptoms. For patients with FHS, particularly with hypertension, we advise that clinicians should consider at least one MRA (Magnetic Resonance Imaging with Angiography) to check for cerebral aneurysms.

Cognitive Correlates of MRI-defined Cerebral Vascular Injury and Atrophy in Elderly American Indians: The Strong Heart Study.

OBJECTIVE: American Indians experience substantial health disparities relative to the US population, including vascular brain aging. Poorer cognitive test performance has been associated with cranial magnetic resonance imaging findings in aging community populations, but no study has investigated these associations in elderly American Indians. METHODS: We examined 786 American Indians aged 64 years and older from the Cerebrovascular Disease and its Consequences in American Indians study (2010-2013). Cranial magnetic resonance images were scored for cortical and subcortical infarcts, hemorrhages, severity of white matter disease, sulcal widening, ventricle enlargement, and volumetric estimates for white matter hyperintensities (WMHs), hippocampus, and brain. Participants completed demographic, medical history, and neuropsychological assessments including testing for general cognitive functioning, verbal learning and memory, processing speed, phonemic fluency, and executive function. RESULTS: Processing speed was independently associated with the presence of any infarcts, white matter disease, and hippocampal and brain volumes, independent of socioeconomic, language, education, and clinical factors. Other significant associations included general cognitive functioning with hippocampal volume. Nonsignificant, marginal associations included general cognition with WMH and brain volume; verbal memory with hippocampal volume; verbal fluency and executive function with brain volume; and processing speed with ventricle enlargement. CONCLUSIONS: Brain-cognition associations found in this study of elderly American Indians are similar to those found in other racial/ethnic populations, with processing speed comprising an especially strong correlate of cerebrovascular disease. These findings may assist future efforts to define opportunities for disease prevention, to conduct research on diagnostic and normative standards, and to guide clinical evaluation of this underserved and overburdened population.

In-hospital cardiopulmonary resuscitation of patients with cirrhosis: A population-based analysis.

OBJECTIVE: To examine the epidemiology and outcomes of in-hospital cardiopulmonary resuscitation (CPR) among patients with cirrhosis. METHODS: We used the Texas Inpatient Public Use Data File to identify hospitalizations aged ≥ 18 years with and without cirrhosis during 2009-2014 and those in each group who have undergone in-hospital CPR. Short-term survival (defined as absence of hospital mortality or discharge to hospice) following in-hospital CPR was examined. Multivariate logistic regression modeling was used to assess the prognostic impact of cirrhosis following in-hospital CPR and predictors of short-term survival among cirrhosis hospitalizations. RESULTS: In-hospital CPR was reported in 2,511 and 51,969 hospitalizations with and without cirrhosis, respectively. The rate of in-hospital CPR (per 1,000 hospitalizations) was 7.6 and 4.0 among hospitalizations with and without cirrhosis, respectively. The corresponding rate of in-hospital CPR among decedents was 10.7% and 13.4%, respectively. Short-term survival following in-hospital CPR among hospitalizations with and without cirrhosis was 14.9% and 27.3%, respectively, and remained unchanged over time on adjusted analyses among the former (p = 0.1753), while increasing among the latter (p = 0.0404). Cirrhosis was associated with lower odds of short-term survival following in-hospital CPR (adjusted odds ratio [aOR] 0.55 [95% CI: 0.49-0.62]). Lack of health insurance (vs. Medicare) (aOR] 0.47 [95% CI: 0.34-0.67]) and sepsis ([aOR] 0.67 [95% CI: 0.53-85]) were associated with lower odds of short-term survival following in-hospital CPR among cirrhosis hospitalizations. CONCLUSIONS: The rate of in-hospital CPR was nearly 2-fold higher among hospitalizations with cirrhosis than among those without it, though it was used more selectively among the former. Short-term survival following in-hospital CPR remained markedly lower among cirrhosis hospitalizations, while progressively improving among those without cirrhosis. Strategies to increase access to health insurance and improve early identification and control of infection should be explored in future preventive and interventional efforts.

Trends and inequalities in the burden of mortality in Scotland 2000-2015.

BACKGROUND: Cause-specific mortality trends are routinely reported for Scotland. However, ill-defined deaths are not routinely redistributed to more precise and internationally comparable categories nor is the mortality reported in terms of years of life lost to facilitate the calculation of the burden of disease. This study describes trends in Years of Life Lost (YLL) for specific causes of death in Scotland from 2000 to 2015. METHODS: We obtained records of all deaths in Scotland by age, sex, area and underlying cause of death between 2000 and 2015. We redistributed Ill-Defined Deaths (IDDs) to more exact and meaningful causes using internationally accepted methods. Years of Life Lost (YLL) using remaining life expectancy by sex and single year of age from the 2013 Scottish life table were calculated for each death. These data were then used to calculate the crude and age-standardised trends in YLL by age, sex, cause, health board area, and area deprivation decile. RESULTS: Between 2000 and 2015, the annual percentage of deaths that were ill-defined varied between 10% and 12%. The proportion of deaths that were IDDs increased over time and were more common: in women; amongst those aged 1-4 years, 25-34 years and >80 years; in more deprived areas; and in the island health boards. The total YLL fell from around 17,800 years per 100,000 population in 2000 to around 13,500 years by 2015. The largest individual contributors to YLL were Ischaemic Heart Disease (IHD), respiratory cancers, Chronic Obstructive Pulmonary Disease (COPD), cerebrovascular disease and Alzheimer's/dementia. The proportion of total YLL due to IHD and stroke declined over time, but increased for Alzheimer's/dementia and drug use disorders. There were marked absolute inequalities in YLL by area deprivation, with a mean Slope Index of Inequality (SII) for all causes of 15,344 YLL between 2001 and 2015, with IHD and COPD the greatest contributors. The Relative Index of Inequality (RII) for YLL was highest for self-harm and lower respiratory infections. CONCLUSION: The total YLL per 100,000 population in Scotland has declined over time. The YLL in Scotland is predominantly due to a wide range of chronic diseases, substance misuse, self-harm and increasingly Alzheimer's disease and dementia. Inequalities in YLL, in both relative and absolute terms, are stark.

Assessment of intracranial vessels in association with carotid atherosclerosis and brain vascular lesions in rheumatoid arthritis.

BACKGROUND: Stroke has been associated with rheumatoid arthritis (RA). We assessed patients with RA and healthy control subjects by transcranial Doppler (TCD), carotid ultrasonography and brain magnetic resonance imaging (MRI). METHODS: Altogether, 41 female patients with RA undergoing methotrexate (MTX) or biologic treatment and 60 age-matched control subjects underwent TCD assessment of the middle cerebral artery (MCA) and basilar artery. Pulsatility index (PI), resistivity (resistance) index (RI) and circulatory reserve capacity (CRC) were determined at rest (r) and after apnoea (a) and hyperventilation (h). The presence of carotid plaques and carotid intima-media thickness (cIMT) were also determined. Intracerebral vascular lesions were investigated by brain MRI. RESULTS: MCA PI and RI values at rest and after apnoea were significantly increased in the total and MTX-treated RA populations vs control subjects. MCA CRC was also impaired, and basilar artery PI was higher in RA. More patients with RA had carotid plaques and increased cIMT. Linear regression analysis revealed that left PI(r) and RI(r) correlated with disease duration and that left PI(r), RI(r), PI(a), PI(h) and basilar PI correlated with disease activity. Right CRC inversely correlated with 28-joint Disease Activity Score. Disease activity was an independent determinant of left PI(a) and right CRC. Compared with long-term MTX treatment alone, the use of biologics in combination with MTX was associated with less impaired cerebral circulation. Impaired cerebral circulation was also associated with measures of carotid atherosclerosis. CONCLUSIONS: To our knowledge, this is the first study to show increased distal MCA and basilar artery occlusion in RA as determined by TCD. Patients with RA also had CRC defects. We also confirmed increased carotid plaque formation and increased cIMT. Biologics may beneficially influence some parameters in the intracranial vessels.

Medicare Expenditure Correlates of Atrophy and Cerebrovascular Disease in Older Adults.

Background/Study Context: Magnetic resonance imaging (MRI) markers of cerebrovascular disease and atrophy are common in older adults and are associated with cognitive and medical burden. However, the extent to which they are related to health care expenditures has not been examined. We studied whether increased Medicare expenditures were associated with brain markers of atrophy and cerebrovascular disease in older adults. METHODS: A subset of participants (n = 592; mean age = 80 years; 66% women) from the Washington Heights Inwood Columbia Aging Project (WHICAP), a community-based observational study of aging in upper Manhattan, received high-resolution MRI and had Medicare expenditure data on file. We examined the relationship of common markers of cerebrovascular disease (i.e., white matter hyperintensities and presence of infarcts) and atrophy (i.e., whole brain and hippocampal volume) with Medicare expenditure data averaged over a 10-year period. Main outcome measures were (a) mean Medicare payment per year across the 10-year interval; (b) mean payment for outpatient care per year; and (c) mean payment for inpatient care per year of visit. In addition, we calculated the ratio of mean inpatient spending to mean outpatient spending as well as the ratio of mean inpatient spending to mean total Medicare spending. RESULTS: Increased Medicare spending was associated with higher white matter hyperintensity volume, presence of cerebral infarcts, and smaller total brain volume. When examining specific components of Medicare expenditures, we found that inpatient spending was strongly associated with white matter hyperintensity volume and that increased ratios of inpatient to outpatient and inpatient to total spending were associated with infarcts. CONCLUSION: Medicare costs are related to common markers of "silent" cerebrovascular disease and atrophy.

Post-mortem assessment in vascular dementia: advances and aspirations.

BACKGROUND: Cerebrovascular lesions are a frequent finding in the elderly population. However, the impact of these lesions on cognitive performance, the prevalence of vascular dementia, and the pathophysiology behind characteristic in vivo imaging findings are subject to controversy. Moreover, there are no standardised criteria for the neuropathological assessment of cerebrovascular disease or its related lesions in human post-mortem brains, and conventional histological techniques may indeed be insufficient to fully reflect the consequences of cerebrovascular disease. DISCUSSION: Here, we review and discuss both the neuropathological and in vivo imaging characteristics of cerebrovascular disease, prevalence rates of vascular dementia, and clinico-pathological correlations. We also discuss the frequent comorbidity of cerebrovascular pathology and Alzheimer's disease pathology, as well as the difficult and controversial issue of clinically differentiating between Alzheimer's disease, vascular dementia and mixed Alzheimer's disease/vascular dementia. Finally, we consider additional novel approaches to complement and enhance current post-mortem assessment of cerebral human tissue. CONCLUSION: Elucidation of the pathophysiology of cerebrovascular disease, clarification of characteristic findings of in vivo imaging and knowledge about the impact of combined pathologies are needed to improve the diagnostic accuracy of clinical diagnoses.

Design and methods of the NiCK study: neurocognitive assessment and magnetic resonance imaging analysis of children and young adults with chronic kidney disease.

BACKGROUND: Chronic kidney disease is strongly linked to neurocognitive deficits in adults and children, but the pathophysiologic processes leading to these deficits remain poorly understood. The NiCK study (Neurocognitive Assessment and Magnetic Resonance Imaging Analysis of Children and Young Adults with Chronic Kidney Disease) seeks to address critical gaps in our understanding of the biological basis for neurologic abnormalities in chronic kidney disease. In this report, we describe the objectives, design, and methods of the NiCK study. DESIGN/METHODS: The NiCK Study is a cross-sectional cohort study in which neurocognitive and neuroimaging phenotyping is performed in children and young adults, aged 8 to 25 years, with chronic kidney disease compared to healthy controls. Assessments include (1) comprehensive neurocognitive testing (using traditional and computerized methods); (2) detailed clinical phenotyping; and (3) multimodal magnetic resonance imaging (MRI) to assess brain structure (using T1-weighted MRI, T2-weighted MRI, and diffusion tensor imaging), functional connectivity (using functional MRI), and blood flow (using arterial spin labeled MRI). Primary analyses will examine group differences in neurocognitive testing and neuroimaging between subjects with chronic kidney disease and healthy controls. Mechanisms responsible for neurocognitive dysfunction resulting from kidney disease will be explored by examining associations between neurocognitive testing and regional changes in brain structure, functional connectivity, or blood flow. In addition, the neurologic impact of kidney disease comorbidities such as anemia and hypertension will be explored. We highlight aspects of our analytical approach that illustrate the challenges and opportunities posed by data of this scope. DISCUSSION: The NiCK study provides a unique opportunity to address key questions about the biological basis of neurocognitive deficits in chronic kidney disease. Understanding these mechanisms could have great public health impact by guiding screening strategies, delivery of health information, and targeted treatment strategies for chronic kidney disease and its related comorbidities.

Neuropathologic assessment of dementia markers in identical and fraternal twins.

Twin studies are an incomparable source of investigation to shed light on genetic and non-genetic components of neurodegenerative diseases, as Alzheimer's disease (AD). Detailed clinicopathologic correlations using twin longitudinal data and post-mortem examinations are mostly missing. We describe clinical and pathologic findings of seven monozygotic (MZ) and dizygotic (DZ) twin pairs. Our findings show good agreement between clinical and pathologic diagnoses in the majority of the twin pairs, with greater neuropathologic concordance in MZ than DZ twins. Greater neuropathologic concordance was found for ß-amyloid than tau pathology within the pairs. ApoE4 was associated with higher ß-amyloid and earlier dementia onset, and importantly, higher frequency of other co-occurring brain pathologies, regardless of the zygosity. Dementia onset, dementia duration, difference between twins in age at dementia onset and at death, did not correlate with AD pathology. These clinicopathologic correlations of older identical and fraternal twins support the relevance of genetic factors in AD, but not their sufficiency to determine the pathology, and consequently the disease, even in monozygotic twins. It is the interaction among genetic and non-genetic risks which plays a major role in influencing, or probably determining, the degeneration of those brain circuits associated with pathology and cognitive deficits in AD.

Cerebrovascular profile assessment in Parkinson's disease patients.

INTRODUCTION: Parkinson's disease (PD) is one of the most common neurodegenerative diseases, and PD patients can present a variety of comorbidities that increase with age. Among them, cardiovascular and cerebrovascular diseases are the most prominent. AIM: To assess the cardiovascular and cerebrovascular profiles of PD patients. PATIENTS AND METHODS: The cardiovascular risk factors of 126 PD patients were assessed according to laboratory tests (fasting blood sugar, serum cholesterol, triglycerides, and total lipids), Doppler ultrasound examinations and personal histories of cerebrovascular disease (ischemic/hemorrhagic), cardiovascular disease (myocardial infarct or angina confirmed by electrocardiogram), hypertension and diabetes. All patients underwent cerebral structural imaging procedures: computed tomography or magnetic resonance imaging. RESULTS: 58.73% of the patients presented with hypertension, with a slight predominance of female patients (65.38% vs 47.92%, P = 0.05). Carotid or vertebral atheromatosis was present in 39 (30.95%) and 28 (22.22%) of patients, respectively, and was statistically correlated with the presence of ischemic lesions on cerebral imaging. Regarding the computed tomography findings, 33 patients (28.21%) presented with cortical atrophy that was not correlated with any of the investigated cardiovascular factors. CONCLUSIONS: Our findings indicate that risk factors for cardiovascular and cerebrovascular diseases are common in PD patients, possibly due to their older age. The presence of atherosclerosis and its complications can be detected in cerebral imaging studies.

National Institute on Aging-Alzheimer's Association guidelines for the neuropathologic assessment of Alzheimer's disease: a practical approach.

We present a practical guide for the implementation of recently revised National Institute on Aging-Alzheimer's Association guidelines for the neuropathologic assessment of Alzheimer's disease (AD). Major revisions from previous consensus criteria are: (1) recognition that AD neuropathologic changes may occur in the apparent absence of cognitive impairment, (2) an "ABC" score for AD neuropathologic change that incorporates histopathologic assessments of amyloid ß deposits (A), staging of neurofibrillary tangles (B), and scoring of neuritic plaques (C), and (3) more detailed approaches for assessing commonly co-morbid conditions such as Lewy body disease, vascular brain injury, hippocampal sclerosis, and TAR DNA binding protein (TDP)-43 immunoreactive inclusions. Recommendations also are made for the minimum sampling of brain, preferred staining methods with acceptable alternatives, reporting of results, and clinico-pathologic correlations.

Clinical utility of quantitative magnetic resonance angiography in the assessment of the underlying pathophysiology in a variety of cerebrovascular disorders.

BACKGROUND: Quantitative MRA (qMRA) is a relatively new technique that uses traditional time-of-flight and phase-contrast MRI to visualize extracranial and intracranial vascular anatomy and measure volumetric blood flow. We aimed to assess the clinical utility of qMRA in assessing the hypothesized pathophysiology (HP) in a range of cerebrovascular diseases. Moreover, we postulated that evaluation of the arterial waveforms, can improve the evaluation of the hypothesized pathophysiology by qMRA. METHODS: We reviewed studies from 10 patients who underwent qMRA examinations before and after their treatments. Two reviewers assessed the anatomy, volumetric flow rates and arterial waveforms for each vessel sampled and reached a consensus as to whether the above parameters supported the clinical diagnosis/hypothesized pathophysiology and the subsequent management. FINDINGS: All 20 qMRA studies were technically adequate. qMRA supported the HP in all 10 patients as determined by abnormal volumetric flow values in the affected vessels before treatment and by the correction of these abnormal values in the patients whose treatment was successful. Each of our five patients with occlusive disease/vasoconstriction demonstrated evidence of dampening of the arterial waveforms distally to the narrowed artery (parvus-tardus phenomenon). The parvus-tardus effect disappeared after treatment. CONCLUSION: qMRA is unique in combining time-of-flight MRA in a complementary manner with phase-contrast MRA to obtain volumetric flow values and potentially important physiologic information from arterial waveform analysis in patients with a range of cerebrovascular diseases during the course of a single MR examination.

Diabetes, hyperglycemia and the management of cerebrovascular disease.

PURPOSE OF REVIEW: Hyperglycemia is frequent in patients with cerebrovascular disease. This review article aims to summarize the recent evidence from observational studies that examined the adverse cerebrovascular effects of dysglycemic states as well as interventional studies assessing intensive management strategies for hyperglycemia. RECENT FINDINGS: In recent years, diabetes, prediabetic states and insulin resistance and their association with cerebrovascular disease were an important focus of research. The cerebrovascular consequences of these metabolic abnormalities were found to extend beyond ischemic stroke to covert brain infarcts, other structural brain changes and to cognitive impairment with and without dementia. Interventional studies did not reveal that more intensive management of chronic hyperglycemia and of hyperglycemia in the setting of acute stroke improves outcome. There is clear evidence, however, that the overall management of multiple risk factors and behavior modification in patients with dysglycemia may reduce the burden of cerebrovascular disease. SUMMARY: Observational studies reveal the growing burden and adverse cerebrovascular effects of dysglycemic states. Currently available interventional studies assessing more intensive strategies for the management of hyperglycemia did not prove, however, to be effective. We discuss the current evidence, pathophysiological considerations and management implications.

[Silent microhemorrhages in patients with symptomatic cerebrovascular disease]. / Microsangrados silentes en pacientes con enfermedad cerebrovascular sintomática.

INTRODUCTION: T2*-weighted gradient echo MRI sequences (T2*-MRI) have made it possible to detect cerebral microhemorrhages (MH) that have been considered as subclinical but whose clinical significance is largely unknown. OBJECTIVE: To establish the frequency of MH in a sample of consecutive symptomatic cerebrovascular disease (SCD) patients, analyzing its associations with different vascular risk factors (VRF) and its clinical significance. METHODS: A total of 198 patients with SCD were consecutively examined using T2*-MRI. Preferential location of MH and associations between MH presence and MH number with VRF, previous antithrombotic treatment and SCD subtypes were analyzed. RESULTS: A total of 52.5% of our patients had MH. The highest frequency of MH was found in hemorrhagic strokes (72.2%), Transitory ischemic attack (TIA) (42.9%) being the group with the lowest frequency. According to the bivariate analysis, the factors associated with the presence of MH were elderly age (72.4+/-10.5 vs 67.7+/-12.7; p 0.004), hypertension (65.4 vs 51.1%; p 0.041), diabetes (35.6 vs 22.3 %; p 0.041) and being under antithrombotic treatment (45.2 vs 28.7 %; p 0.017). According to the multivariate analysis, elderly age (p 0.019; OR: 1.03 [1.01- 1.06]), hypertension (p 0.032; OR: 1.97 [1.06-3.65]), use of antithrombotic treatment (p 0.038; OR: 1.95 [1.04-3.65]) and having a hemorrhagic stroke (p 0.028; OR: 3.63 [1.15- 11.46]) were predictors of MH presence. CONCLUSIONS: The presence of MH is frequent among patients with SCD, this being especially elevated in patients with hemorrhagic stroke. Cerebral MHs are classically associated with VRF classically related with small vessel disease and previously taking antithrombotic treatment.