Joanna Wojczal

Changes in cerebral hemodynamics after carotid stenting: evaluation with CT perfusion studies

PURPOSE To determine changes in cerebral perfusion parameters, based on CT perfusion imaging, in patients after unilateral transluminal angioplasty and stent placement. MATERIAL AND METHODS 74 patients with symptomatic high - grade internal carotid artery stenosis (>70%) were studied with CT perfusion imaging before and - on average - 70 hours and 172 days after carotid stent placement. There were 50 patients with unilateral carotid artery stenosis and 24 with stenosis and accompanying contralateral internal carotid artery occlusion. CT examination was performed using a multidetector helical CT scanner (Light Speed Ultra Advantage, GE Healthcare, USA). Maps showing the absolute values of cerebral blood flow (CBF), cerebral blood volume (CBV) and mean transit time (MTT) were generated. RESULTS In a group with unilateral carotid artery stenosis perfusion deficits were present in 84% of patients, ipsilaterally to stenosis. MTT elongation was noted (6.2-6.8s) together with decreased values of CBF (40-46ml/100g/min) and slightly increased CBV (3.2ml/100g). In this group, 3 days after stenting, 30% of patients had perfusion deficits, and after 6 months only 6%. In a group with carotid artery stenosis and contralateral artery occlusion severe perfusion deficits were noted in both hemispheres and they were present in 100% of patients. 6 months after stenting hypoperfusion was observed only in 17% of patients. CONCLUSIONS Brain perfusion deficits, observed in a majority of patients with carotid artery stenosis tend to improve considerably after carotid artery stenting, in long - term follow up.

Cerebral Vasomotor Reactivity and Extent of White Matter Lesions in Middle-Aged Men With Arterial Hypertension: A Pilot Study

BACKGROUND Cerebrovascular reactivity (CVR) impairment and cerebral white matter lesions (WMLs) are associated in elderly or patients with overt cerebral ischemia. Such association has not been confirmed for asymptomatic middle-aged individuals with risk factors for stroke. We assessed the relationship between the CVR and the presence of WMLs in a middle-aged population-based cohort of hypertensive men. METHODS Magnetic resonance imaging (MRI) and transcranial Doppler (TCD) examination were performed in 54 hypertensive men, all at 60 years of age, without a history of stroke, neurologic deficits, or carotid stenosis. The CVR of the middle cerebral artery (MCA) was expressed as the vasomotor reactivity reserve (VMRr). RESULTS WMLs were detected in 22 men (40.7%); all WMLs were classified as mild (first grade of the Fazekas modified scale). The VMRr was lower in patients with WMLs (mean 55%; s.e. 3%) compared to those without WMLs (mean 65%; s.e. 3%; P = 0.03). The lower VMRr in patients with WMLs was consistent after controlling for confounders. A higher pulsatility index (PI) in subjects with WMLs (mean 1.08; s.e. 0.05) compared to those without WMLs (mean 0.90; s.e. 0.05; P = 0.01) was not consistent after controlling for confounders. CONCLUSIONS The CVR was lower in middle-aged hypertensive men with WMLs compared to those without WMLs indicating that even a low load of WMLs may reflect some functional impairment of the cerebral microvasculature.

Cerebrovascular Reactivity, Intima-Media Thickness, and Nephropathy Presence in Patients With Type 1 Diabetes

OBJECTIVE Cerebrovascular reactivity impairment was reported as a marker of cerebral microangiopathy in long-term type 1 diabetes. Intima-media complex thickening reflects early stages of macroangiopathy in type 1 diabetes. The analysis of the relationship between these variables and other microangiopathic complications might serve as a beneficial indicator for early prophylaxis in these patients. RESEARCH DESIGN AND METHODS Vasomotor reactivity reserve (VMRr) and breath-holding index (BHI) of the middle cerebral artery were measured with transcranial Doppler in 59 patients (median age 32.0 years, range 20–51, 36 females) with type 1 diabetes, without history of cerebrovascular events, and 30 healthy control subjects (median age 31.5 years, range 25–39, 15 females). The relationships between the presence of selected vascular complications of type 1 diabetes and biochemical parameters, intima-media thickness (IMT), and VMRr and BHI in patients were analyzed. RESULTS VMRr and BHI were lower in patients with type 1 diabetes when compared with healthy subjects (81.5 vs. 100%, P < 0.01, and 1.6 vs. 2.2, P = 0.04, respectively), whereas IMT was significantly higher in patients then in healthy control subjects (0.36 vs. 0.30 mm, P = 0.001). However, no association of IMT with VMRr was found. We found a significant reduction of VMRr and BHI in patients with diabetic nephropathy. CONCLUSIONS The presence of diabetic nephropathy, but not IMT, can be regarded as an indicator of cerebral microangiopathy severity in patients with type 1 diabetes.

Monocyte chemoattractant protein (MCP-1) A-2518G gene polymorphism in stroke patients with different comorbidities

OBJECTIVES The aim of our study was to assess the effect of A-2518G polymorphism in the monocyte chemoattractant protein-1 gene on development of stroke. DESIGN AND METHODS A total of 194 patients with stroke and 320 healthy controls were genotyped for the MCP-1 gene -2518 polymorphism. RESULTS There was a significant difference in genotype frequencies between ischemic stroke patients and controls (p=0.01). Stroke patients were subdivided according to gender, presence of renal disease, small-vessel disease, diabetes, atherosclerosis and hyperlipidemia. There were differences in genotype frequencies between stroke patients with atherosclerosis and controls (p=0.03), and in allele frequencies between diabetic patients and controls (p=0.04). In hyperlipidemia, the OR 2.33 for the GG genotype may be due to stroke, because it was found only vs. controls and not vs. group without hyperlipidemia. CONCLUSIONS Our results demonstrate an association between the polymorphism in the regulatory region of MCP-1 gene and susceptibility to ischemic stroke.

B-type natriuretic peptide as a marker of subclinical heart injury during mitoxantrone therapy in MS patients—Preliminary study

The aim of this study was to evaluate the plasma level changes of B-type natriuretic peptide (BNP), biochemical marker of heart failure, and echocardiographic parameters during mitoxantrone treatment in 22 multiple sclerosis (MS) patients (8 males, 14 females, mean age 37.1+/-6.6). Mitoxantrone (after mean cumulative dose of 58.0+/-7.0 mg/m(2)) did not alter left ventricular ejection fraction (LVEF), left ventricular end-diastolic diameter (LVEDD), posterior wall thickness (PWT) and left ventricular end-diastolic volume (LVEDV). However, mean plasma level of BNP raised from 14.53+/-3.29 pg/ml at the baseline to 16.79+/-3.05 pg/ml and 18.83+/-4.90 pg/ml (P<0.01) after mean mitoxantrone dose of 30.7+/-5.9 mg/m(2) and 58.0+/-7.0 mg/m(2), respectively. These results strongly suggest subclinical myocardial dysfunction in mitoxantrone-treated group. We assume, that low-cost, repeated BNP measurements may be a good alternative for detection of early subtle myocardial injury in MS patients during routine mitoxantrone therapy.

Cigarette smoking and cerebral microvasculature in patients with type 1 diabetes: a pilot study

Introduction. A decrease in vasomotor reactivity reserve (VMRr) or an increase in pulsatility index (PI) are the early signs of cerebral microangiopathy in type 1 diabetes. Cigarette smoking is a risk factor for microvascular complications of type 1 diabetes, but cigarette smokers are routinely excluded from studies on VMRr or PI in type 1 diabetes (T1DM) and there is no evidence of any significant impact of smoking on these variables in T1DM. Therefore, we aimed to assess the impact of cigarette smoking on VMRr and PI in these patients. Methods. VMRr and PI of the middle cerebral artery were measured with Transcranial Doppler in 79 patients with T1DM (median age 33.0 years, range 20–51, 44% males) without a history of cerebrovascular events, coronary heart disease or carotid stenosis. The relationship between cigarette smoking (n = 20, mean pack-years 9.4 ± 6.1) and VMRr, PI, concomitant risk factors, medications and the presence of systemic microvascular complications were analysed. Results. Smokers and non-smokers did not differ in terms of their clinical characteristics, with an exception of higher circadian insulin demand in smokers (60 ± 12.9 v. 49.2 ± 14.2 units; p = 0.004). A correlation between pack-years and PI (r = 0.6, p = 0.004), but not with VMRr, was found in smokers. However, no significant differences between smokers and non-smokers were found regarding either VMRr (mean 85.9 ± 20% v. 84.1 ± 20.1%; p = 0.74) or PI (median 0.85, range 0.61–1.09 v. 0.88, range 0.48–1.52; p = 0.2). Conclusions. We did not prove any significant impact of smoking on VMRr in T1DM patients, but the association between pack-years and PI may indicate the negative impact of intensive cigarette smoking on the cerebral microvasculature in type 1 diabetes.

Standards in neurosonology. Part III.

The paper presents standards related to ultrasound imaging of the cerebral vasculature and structures. The aim of this paper is to standardize both the performance and description of ultrasound imaging of the extracranial and intracranial cerebral arteries as well as a study of a specific brain structure, i.e. substantia nigra hyperechogenicity. The following aspects are included in the description of standards for each ultrasonographic method: equipment requirements, patient preparation, study technique and documentation as well as the required elements of ultrasound description. Practical criteria for the diagnosis of certain pathologies in accordance with the latest literature were also presented. Furthermore, additional comments were included in some of the sections. Part I discusses standards for the performance, documentation and description of different ultrasound methods (Duplex, Doppler). Part II and III are devoted to standards for specific clinical situations (vasospasm, monitoring after the acute stage of stroke, detection of a right-toleft shunts, confirmation of the arrest of the cerebral circulation, an assessment of the functional efficiency of circle of Willis, an assessment of the cerebrovascular vasomotor reserve as well as the measurement of substantia nigra hyperechogenicity).

Standardy badań ultrasonograficznych. Neurosonologia. Część III

The paper presents standards related to ultrasound imaging of the cerebral vasculature and structures. The aim of this paper is to standardize both the performance and description of ultrasound imaging of the extracranial and intracranial cerebral arteries as well as a study of a specific brain structure, i.e. substantia nigra hyperechogenicity. The following aspects are included in the description of standards for each ultrasonographic method: equipment requirements, patient preparation, study technique and documentation as well as the required elements of ultrasound description. Practical criteria for the diagnosis of certain pathologies in accordance with the latest literature were also presented. Furthermore, additional comments were included in some of the sections. Part I discusses standards for the performance, documentation and description of different ultrasound methods (Duplex, Doppler). Part II and III are devoted to standards for specific clinical situations (vasospasm, monitoring after the acute stage of stroke, detection of a right-to-left shunts, confirmation of the arrest of the cerebral circulation, an assessment of the functional efficiency of circle of Willis, an assessment of the cerebrovascular vasomotor reserve as well as the measurement of substantia nigra hyperechogenicity).

Predictors of intracranial cerebral artery stenosis in patients before cardiac surgery and its impact on perioperative and long-term stroke risk

BACKGROUND The aim of this prospective study was to determine the prevalence of stenosis within intracranial and extracranial arteries in patients before coronary artery bypass surgery (CABG), to evaluate the influence of intracranial artery stenosis on neurological outcome and to identify preoperative risk factors for these patients. METHODS One hundred and seventy-five patients (71% males, mean age=66.1) scheduled for CABG were enrolled for extracranial Doppler duplex sonography, transcranial color-coded duplex sonography (TCCS) and transcranial Doppler (TCD) examination. RESULTS Twenty-six patients (14.7%) had extracranial stenosis or occlusion and 13 patients (7.3%) intracranial vascular disease. Six patients (3.5%) had both extra- and intracranial artery disease. The presence of peripheral artery disease and diabetes mellitus was a strong risk factor for extracranial artery stenosis but not for intracranial artery stenosis, which occurred independently also of typical atherosclerotic risk factors like age >70, male sex, hypertension, hyperlipidemia, hyperhomocysteinemia, smoking habit, obesity (BMI>30) and waist to hip ratio >1. Functional neurological outcome of the patients with intracranial arterial disease evaluated 7 days after CABG was the same as the patients without extra- and intracranial stenosis. However, 12-months neurological follow-up revealed significantly more ischemic strokes in patients with intracranial artery stenosis compared to patients without intracranial stenosis (p=0.015). CONCLUSION The occurrence of intracranial artery stenosis in CABG patients cannot be predicted by well-known atherosclerotic risk factors and seems not to be associated with perioperative stroke.