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Stroke Jun 2023Large vessel occlusion stroke due to underlying intracranial atherosclerotic disease (ICAD-LVO) is prevalent in 10 to 30% of LVOs depending on patient factors such as... (Review)
Review
Large vessel occlusion stroke due to underlying intracranial atherosclerotic disease (ICAD-LVO) is prevalent in 10 to 30% of LVOs depending on patient factors such as vascular risk factors, race and ethnicity, and age. Patients with ICAD-LVO derive similar functional outcome benefit from endovascular thrombectomy as other mechanisms of LVO, but up to half of ICAD-LVO patients reocclude after revascularization. Therefore, early identification and treatment planning for ICAD-LVO are important given the unique considerations before, during, and after endovascular thrombectomy. In this review of ICAD-LVO, we propose a multistep approach to ICAD-LVO identification, pretreatment and endovascular thrombectomy considerations, adjunctive medications, and medical management. There have been no large-scale randomized controlled trials dedicated to studying ICAD-LVO, therefore this review focuses on observational studies.
Topics: Humans; Stroke; Thrombectomy; Intracranial Arteriosclerosis; Treatment Outcome; Endovascular Procedures; Retrospective Studies; Brain Ischemia
PubMed: 36938708
DOI: 10.1161/STROKEAHA.122.040008 -
JAMA Aug 2023Prior trials of extracranial-intracranial (EC-IC) bypass surgery showed no benefit for stroke prevention in patients with atherosclerotic occlusion of the internal... (Randomized Controlled Trial)
Randomized Controlled Trial
IMPORTANCE
Prior trials of extracranial-intracranial (EC-IC) bypass surgery showed no benefit for stroke prevention in patients with atherosclerotic occlusion of the internal carotid artery (ICA) or middle cerebral artery (MCA), but there have been subsequent improvements in surgical techniques and patient selection.
OBJECTIVE
To evaluate EC-IC bypass surgery in symptomatic patients with atherosclerotic occlusion of the ICA or MCA, using refined patient and operator selection.
DESIGN, SETTING, AND PARTICIPANTS
This was a randomized, open-label, outcome assessor-blinded trial conducted at 13 centers in China. A total of 324 patients with ICA or MCA occlusion with transient ischemic attack or nondisabling ischemic stroke attributed to hemodynamic insufficiency based on computed tomography perfusion imaging were recruited between June 2013 and March 2018 (final follow-up: March 18, 2020).
INTERVENTIONS
EC-IC bypass surgery plus medical therapy (surgical group; n = 161) or medical therapy alone (medical group; n = 163). Medical therapy included antiplatelet therapy and stroke risk factor control.
MAIN OUTCOMES AND MEASURES
The primary outcome was a composite of stroke or death within 30 days or ipsilateral ischemic stroke beyond 30 days through 2 years after randomization. There were 9 secondary outcomes, including any stroke or death within 2 years and fatal stroke within 2 years.
RESULTS
Among 330 patients who were enrolled, 324 patients were confirmed eligible (median age, 52.7 years; 257 men [79.3%]) and 309 (95.4%) completed the trial. For the surgical group vs medical group, no significant difference was found for the composite primary outcome (8.6% [13/151] vs 12.3% [19/155]; incidence difference, -3.6% [95% CI, -10.1% to 2.9%]; hazard ratio [HR], 0.71 [95% CI, 0.33-1.54]; P = .39). The 30-day risk of stroke or death was 6.2% (10/161) in the surgical group and 1.8% (3/163) in the medical group, and the risk of ipsilateral ischemic stroke beyond 30 days through 2 years was 2.0% (3/151) and 10.3% (16/155), respectively. Of the 9 prespecified secondary end points, none showed a significant difference including any stroke or death within 2 years (9.9% [15/152] vs 15.3% [24/157]; incidence difference, -5.4% [95% CI, -12.5% to 1.7%]; HR, 0.69 [95% CI, 0.34-1.39]; P = .30) and fatal stroke within 2 years (2.0% [3/150] vs 0% [0/153]; incidence difference, 1.9% [95% CI, -0.2% to 4.0%]; P = .08).
CONCLUSIONS AND RELEVANCE
Among patients with symptomatic ICA or MCA occlusion and hemodynamic insufficiency, the addition of bypass surgery to medical therapy did not significantly change the risk of the composite outcome of stroke or death within 30 days or ipsilateral ischemic stroke beyond 30 days through 2 years.
TRIAL REGISTRATION
ClinicalTrials.gov Identifier: NCT01758614.
Topics: Female; Humans; Male; Middle Aged; Arteriosclerosis; Carotid Artery Diseases; Carotid Artery, Internal; Cerebral Revascularization; Infarction, Middle Cerebral Artery; Intracranial Arteriosclerosis; Ischemic Attack, Transient; Ischemic Stroke; Middle Cerebral Artery; Perfusion Imaging; Single-Blind Method; Stroke; Tomography, Emission-Computed; Platelet Aggregation Inhibitors; Combined Modality Therapy
PubMed: 37606672
DOI: 10.1001/jama.2023.13390 -
Journal of Atherosclerosis and... Mar 2022Iron is an important element for life; however, intracellular labile iron overload can lead to the generation of reactive oxygen species and cellular damage. Although... (Review)
Review
Iron is an important element for life; however, intracellular labile iron overload can lead to the generation of reactive oxygen species and cellular damage. Although iron is mainly utilized for heme synthesis and is incorporated into hemoglobin, body iron status is often implicated in the pathogenesis of cardiovascular diseases. In a cell, iron is used for basic processes such as cell growth, maintenance, and repair. Thus, iron is considered to be involved in the pathogenesis of arteriosclerosis. In fact, clinical and experimental studies have shown an association between iron and arteriosclerosis. These data suggest the crosstalk between iron and arteriosclerosis. However, iron metabolism in arteriosclerosis is often complicated, and the systemic and cellular mechanisms of iron homeostasis in arteriosclerosis remain completely unsolved. Thus, in this review, we aimed to examine the role of iron in arteriosclerosis.
Topics: Animals; Arteriosclerosis; Homeostasis; Humans; Iron Overload; Oxidative Stress; Reactive Oxygen Species
PubMed: 34421089
DOI: 10.5551/jat.RV17060 -
Circulation Jul 2023Asian American individuals make up the fastest growing racial and ethnic group in the United States. Despite the substantial variability that exists in type 2 diabetes... (Review)
Review
Epidemiology of Diabetes and Atherosclerotic Cardiovascular Disease Among Asian American Adults: Implications, Management, and Future Directions: A Scientific Statement From the American Heart Association.
Asian American individuals make up the fastest growing racial and ethnic group in the United States. Despite the substantial variability that exists in type 2 diabetes and atherosclerotic cardiovascular disease risk among the different subgroups of Asian Americans, the current literature, when available, often fails to examine these subgroups individually. The purpose of this scientific statement is to summarize the latest disaggregated data, when possible, on Asian American demographics, prevalence, biological mechanisms, genetics, health behaviors, acculturation and lifestyle interventions, pharmacological therapy, complementary alternative interventions, and their impact on type 2 diabetes and atherosclerotic cardiovascular disease. On the basis of available evidence to date, we noted that the prevalences of type 2 diabetes and stroke mortality are higher in all Asian American subgroups compared with non-Hispanic White adults. Data also showed that atherosclerotic cardiovascular disease risk is highest among South Asian and Filipino adults but lowest among Chinese, Japanese, and Korean adults. This scientific statement discusses the biological pathway of type 2 diabetes and the possible role of genetics in type 2 diabetes and atherosclerotic cardiovascular disease among Asian American adults. Challenges to provide evidence-based recommendations included the limited data on Asian American adults in risk prediction models, national surveillance surveys, and clinical trials, leading to significant research disparities in this population. The large disparity within this population is a call for action to the public health and clinical health care community, for whom opportunities for the inclusion of the Asian American subgroups should be a priority. Future studies of atherosclerotic cardiovascular disease risk in Asian American adults need to be adequately powered, to incorporate multiple Asian ancestries, and to include multigenerational cohorts. With advances in epidemiology and data analysis and the availability of larger, representative cohorts, furthering refining the Pooled Cohort Equations, in addition to enhancers, would allow better risk estimation in segments of the population. Last, this scientific statement provides individual- and community-level intervention suggestions for health care professionals who interact with the Asian American population.
Topics: Adult; Humans; American Heart Association; Asian; Atherosclerosis; Cardiovascular Diseases; Diabetes Mellitus, Type 2; United States
PubMed: 37154053
DOI: 10.1161/CIR.0000000000001145 -
Journal of the American College of... May 2018Coronary artery disease (CAD) is a major cause of morbidity and mortality in patients ≥80 years of age. Nonetheless, older patients have typically been...
Coronary artery disease (CAD) is a major cause of morbidity and mortality in patients ≥80 years of age. Nonetheless, older patients have typically been under-represented in cardiovascular clinical trials. Understanding the pathophysiology, epidemiology, and optimal means of diagnosis and treatment of CAD in older adults is crucial to improving outcomes in this high-risk population. A patient-centered approach, taking into account health status, functional ability and frailty, cognitive skills, and patient preferences is essential when caring for older adults with CAD. The present systematic review focuses on the current knowledge base, gaps in understanding, and directions for future investigation pertaining to CAD in patients ≥80 years of age.
Topics: Aged, 80 and over; Coronary Artery Disease; Humans
PubMed: 29724356
DOI: 10.1016/j.jacc.2017.12.068 -
Acta Neuropathologica Jan 2021Brain arteriolosclerosis (B-ASC), characterized by pathologic arteriolar wall thickening, is a common finding at autopsy in aged persons and is associated with cognitive... (Review)
Review
Brain arteriolosclerosis (B-ASC), characterized by pathologic arteriolar wall thickening, is a common finding at autopsy in aged persons and is associated with cognitive impairment. Hypertension and diabetes are widely recognized as risk factors for B-ASC. Recent research indicates other and more complex risk factors and pathogenetic mechanisms. Here, we describe aspects of the unique architecture of brain arterioles, histomorphologic features of B-ASC, relevant neuroimaging findings, epidemiology and association with aging, established genetic risk factors, and the co-occurrence of B-ASC with other neuropathologic conditions such as Alzheimer's disease and limbic-predominant age-related TDP-43 encephalopathy (LATE). There may also be complex physiologic interactions between metabolic syndrome (e.g., hypertension and inflammation) and brain arteriolar pathology. Although there is no universally applied diagnostic methodology, several classification schemes and neuroimaging techniques are used to diagnose and categorize cerebral small vessel disease pathologies that include B-ASC, microinfarcts, microbleeds, lacunar infarcts, and cerebral amyloid angiopathy (CAA). In clinical-pathologic studies that factored in comorbid diseases, B-ASC was independently associated with impairments of global cognition, episodic memory, working memory, and perceptual speed, and has been linked to autonomic dysfunction and motor symptoms including parkinsonism. We conclude by discussing critical knowledge gaps related to B-ASC and suggest that there are probably subcategories of B-ASC that differ in pathogenesis. Observed in over 80% of autopsied individuals beyond 80 years of age, B-ASC is a complex and under-studied contributor to neurologic disability.
Topics: Aged; Aged, 80 and over; Animals; Arterioles; Brain; Cerebral Amyloid Angiopathy; Cognition Disorders; Humans; Intracranial Arteriosclerosis; Neuroimaging
PubMed: 33098484
DOI: 10.1007/s00401-020-02235-6 -
Neurobiology of Disease Apr 2019Intracranial atherosclerosis (ICAS) is a progressive pathological process that causes progressive stenosis and cerebral hypoperfusion and is a major cause of stroke... (Review)
Review
Intracranial atherosclerosis (ICAS) is a progressive pathological process that causes progressive stenosis and cerebral hypoperfusion and is a major cause of stroke occurrence and recurrence around the world. Multiple factors contribute to the development of ICAS. Angiography imaging techniques can improve the diagnosis of and the selection of appropriate treatment regimens for ICAS. Neither aggressive medication nor endovascular interventions can eradicate stroke recurrence in patients with ICAS. Non-pharmacological therapies such as remote ischemic conditioning and hypothermia are emerging. Comprehensive therapy with medication in combination with endovascular intervention and/or non-pharmacological treatment may be a potential strategy for ICAS treatment in the future. We summarized the epidemiology, pathophysiological mechanisms, risk factors, biomarkers, imaging and management of ICAS.
Topics: Animals; Brain; Humans; Intracranial Arteriosclerosis; Risk Factors; Stroke
PubMed: 30439443
DOI: 10.1016/j.nbd.2018.11.008 -
Circulation Mar 2019This scientific statement presents considerations for clinical management regarding the assessment and risk reduction of select pediatric populations at high risk for...
This scientific statement presents considerations for clinical management regarding the assessment and risk reduction of select pediatric populations at high risk for premature cardiovascular disease, including acquired arteriosclerosis or atherosclerosis. For each topic, the evidence for accelerated acquired coronary artery disease and stroke in childhood and adolescence and the evidence for benefit of interventions in youth will be reviewed. Children and adolescents may be at higher risk for cardiovascular disease because of significant atherosclerotic or arteriosclerotic risk factors, high-risk conditions that promote atherosclerosis, or coronary artery or other cardiac or vascular abnormalities that make the individual more vulnerable to the adverse effects of traditional cardiovascular risk factors. Existing scientific statements and guidelines will be referenced when applicable, and suggestions for risk identification and reduction specific to each setting will be described. This statement is directed toward pediatric cardiologists, primary care providers, and subspecialists who provide clinical care for these young patients. The focus will be on management and justification for management, minimizing information on pathophysiology and epidemiology.
Topics: Adolescent; American Heart Association; Atherosclerosis; Child; Child, Preschool; Coronary Artery Disease; Female; Humans; Infant; Male; Practice Guidelines as Topic; Risk Factors; United States
PubMed: 30798614
DOI: 10.1161/CIR.0000000000000618 -
Biomedicine & Pharmacotherapy =... Feb 2021Nanomedicines offer nanoscale drug delivery system. They offer ways of promising drug transportation, and address the issues of lack of targeting and permeability of... (Review)
Review
Nanomedicines offer nanoscale drug delivery system. They offer ways of promising drug transportation, and address the issues of lack of targeting and permeability of traditional drugs. The physical and chemical properties in the domain of nanomedicine applications in vivo have not been sufficiently delivered. What's more, the metabolic of nanomedicines is not clear enough. Those factors which mentioned above determine that many nanomedicines have not yet realized clinical application due to their safety problems and in vivo efficacy. For example, they may cause immune response and cytotoxicity, as well as the ability to clear organs in vivo, the penetration ability of them and the lack of targeting ability may also cause poor efficacy of drugs in vivo. In this review, the new progresses of different kinds of nanomedicines (including gold nanoparticles, nanorobots, black phosphorus nanoparticles, brain diseases, gene editing and immunotherapy etc.) in anti-tumor, antibacterial, ocular diseases and arteriosclerosis in recent years were summarized. Their shortcomings were pointed out, and the new methods to improve the biosafety and efficacy were summarized.
Topics: Animals; Arteriosclerosis; Brain Diseases; Drug Delivery Systems; Eye Diseases; Gold; Humans; Immunotherapy; Medicine, Traditional; Metal Nanoparticles; Nanomedicine; Nanoparticles; Nanotechnology; Neoplasms; Phosphorus
PubMed: 33338747
DOI: 10.1016/j.biopha.2020.111103 -
Frontiers of Neurology and Neuroscience 2016Within the intracranial vasculature, atherosclerosis occurs in two distinctive patterns: (1) in Western populations who have severe extracranial and systemic... (Review)
Review
Within the intracranial vasculature, atherosclerosis occurs in two distinctive patterns: (1) in Western populations who have severe extracranial and systemic atherosclerosis, the severity of intracranial involvement is consistently less than that within extracranial arteries; and (2) in Asians, Africans, and Hispanics, who often have isolated intracranial arterial disease that is found to be more often accompanied by brain infarction than comparable extracranial atherosclerotic disease. Compared to coronary and extracranial carotid atherosclerosis, intracranial atherosclerosis has distinct pathological characteristics compared to that of extracranial arteries. Intracranial atherosclerosis (ICAS) had been understudied due to the relative inaccessibility of cerebral artery specimens under current treatment strategies. Acquiring post-mortem cerebral vessel specimens for histology processing is the most direct method to analyze the pathological characteristics of ICAS, in order to analyze both lumen stenosis and plaque components contributing to brain infarctions. The developments in high resolution magnetic resonance imaging (HRMRI) make it feasible to assess human ICAS in vivo. It is nevertheless challenging to understand vessel wall changes within brain vasculature demonstrated on HRMRI, as well as to identify biomarkers for stroke risk stratification and treatment strategy modification. Knowledge about intracranial atherosclerosis remains limited due to lack of human arterial specimens, and the development of proper animal models of human cerebral atherosclerosis is necessary to explore the pathogenesis of intracranial atherosclerosis and to assess various strategies preventing or treating ICAS-related stroke.
Topics: Cerebral Arteries; Humans; Intracranial Arteriosclerosis
PubMed: 27960191
DOI: 10.1159/000448267