American Heart Association

Life Course Epidemiological Trends and Social Determinants in Brain Health

Dixon Yang, MD

Hilal S, Brayne C. Epidemiologic Trends, Social Determinants, and Brain Health: The Role of Life Course Inequalities. Stroke. 2022;53:437–443.

In this focused update, Drs. Hilal and Brayne discuss the role of life course inequalities in brain health and successful aging. Brain health is defined as the development and preservation of optimal brain integrity and neural network functioning for a given age [1]. Sustained brain health over a lifespan is important in the maintenance of an individual’s ability and independence. Poor brain health may manifest as cognitive impairment or stroke in later life. Especially as the proportion of the older population increases worldwide, maintaining brain health will likely become a growing public health challenge. In this article, the authors outline the epidemiological trends and social determinants of health that underpin healthy brain aging. As many of these trends start early in life, Drs. Hilal and Brayne discuss possible mechanisms for healthy brain aging and opportunities for research and societal approaches towards promoting brain health across the lifespan.

By |March 18th, 2022|clinical|Comments Off on Life Course Epidemiological Trends and Social Determinants in Brain Health
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Article Commentary: “Imaging Markers of Vascular Brain Health: Quantification, Clinical Implications, and Future Directions”

Ammad Mahmood, MBChB
@AMahmoodNeuro

Vemuri P, Decarli C, Duering M. Imaging Markers of Vascular Brain Health: Quantification, Clinical Implications, and Future Directions. Stroke. 2022;53:416–426.

Small vessel disease is a common finding on brain imaging which is increasingly identified with the widespread use of MRI. The clinical significance of this finding remains an area requiring further research. This review begins by defining the components and patterns of abnormalities that are encompassed by the term “small vessel disease,” which is widely used but ambiguous in its meaning. Techniques which identify earlier structural and functional changes in the brain in response to vascular risk factors are then discussed. Finally, the clinical implications of these findings and further opportunities for research in this area are highlighted.

By |March 17th, 2022|clinical|Comments Off on Article Commentary: “Imaging Markers of Vascular Brain Health: Quantification, Clinical Implications, and Future Directions”
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ISC 2022 Session: ICH Management: Now and Into the Next Decade

Nurose Karim, MD 

International Stroke Conference 2022 
February 9–11, 2022 
Session: ICH Management: Now and Into the Next Decade 

ICH is a process that leads to many potential targets for intervention. Baseline characteristics (size, GCS, IVH, location and age) predict the outcome. Early hematoma growth leads to tissue disruption and activation of inflammatory markers causing toxic effects and oxidative injury. This causes neuronal injury followed by phagocytosis and active resolution of the inflammation.

Hematoma expansion occurs early, and in about a third of patients, it occurs in the first three hours. The sooner we identify and treat, the earlier we can prevent injury. For ICH, fortunately, we have better metrics. The goal of metrics is to reduce heterogenicity across the board and prevent early neurological deterioration. Due to COVID-19, we have a shortage of beds and nursing staff, and patients are staying in the ED longer than expected. Therefore, we need to train our ED staff to take care of ICH patients and need time metrics to consider: when to repeat imaging? time to ventricular drainage, if indicated? time to operative procedures?

By |March 16th, 2022|clinical, Conference|Comments Off on ISC 2022 Session: ICH Management: Now and Into the Next Decade
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Author Interview: Dr. Steven M. Greenberg on “Vascular Contributions to Brain Health”

Dr. Steven M. Greenberg

A conversation with Dr. Steven M. Greenberg, MD, PhD, Professor of Neurology at Harvard Medical School and John J. Conway Endowed Chair in Neurology, Director of the Hemorrhagic Stroke Research Program and Vice-Chair for Faculty Development and Promotions at the Massachusetts General Hospital.

Interviewed by Kristina Shkirkova, Doctoral Candidate in Neuroscience at the University of Southern California. 

They will be discussing the article “Vascular Contributions to Brain Health: Cross-Cutting Themes.” Published in the February 2022 issue of Stroke, the article introduces a series of Focused Updates articles on topics related to brain health.

Kristina Shkirkova: To set the stage for this interview, could you briefly summarize the current understanding about the importance of vascular health towards brain aging and health span in general?

Dr. Greenberg: We think of brain health as central to healthy aging. Everybody wants to live a long life, but no one wants to live it without the ability to do activities that make you who you are. There is no healthy aging without brain health. It is important to note that vascular brain health is not the only part of brain health, but it is certainly a major part. We see that diseases of the large blood vessels and the small blood vessels (the major focus of this review series) are very common as people age. So almost everybody has some degree of vascular disease with aging. It’s an interesting contrast with some diseases that are less common that cause severe illness. Vascular disease is different: It’s highly prevalent, meaning that many people have it. It’s almost unusual for someone not to have some evidence of vascular disease. The contribution of each individual vascular disease is modest, but it becomes significant when they co-occur and especially if they are added on top of the other kinds of brain changes, such as Alzheimer’s disease. It’s the combination that is worse than either one by itself.

By |March 15th, 2022|author interview, clinical|Comments Off on Author Interview: Dr. Steven M. Greenberg on “Vascular Contributions to Brain Health”
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Slowing Down Progression of White Matter Hyperintensities by Antiplatelets — Too Good to Be True

Thomas Raphael Meinel, MD
@TotoMynell

Kim BC, Youn YC, Jeong JH, Han HJ, Kim JH, Lee J-H, Park KH, Park KW, Kim E-J, Oh MS, et al. Cilostazol Versus Aspirin on White Matter Changes in Cerebral Small Vessel Disease: A Randomized Controlled Trial. Stroke. 2021.

Small-vessel disease, including manifest stroke, but more frequently covert lesions, is a silent pandemic contributing considerably to dementia, frailty, gait problems and mood disorders worldwide.1 The imaging spectrum of small-vessel disease includes white matter hyperintensities (WMH), lacunes, acute small subcortical infarcts, cerebral microbleeds and dilated perivascular spaces.2

It is thus of utmost importance that Kim et al. undertook the work to perform a multicenter, double-blind, randomized controlled trial3 on whether cilostazol slow release (200 mg) as compared to aspirin (100 mg) might be able to slow down WMH progression over the follow-up duration of two years. For this trial, Korean patients aged 50-85 with (45%) and without (55%) manifest stroke were recruited from memory clinics or neurology outpatient clinics referred for memory problems, gait disturbances, personality changes or secondary prevention after a small subcortical infarction or TIA between 2013 and 2016. They had to have at least moderately severe WMH and at least one lacune. Exclusion criteria included contraindications to antiplatelets, significant atherosclerosis or cardioembolic heart disease amongst others. The methods included sophisticated brain imaging and neurocognitive assessments.

By |March 10th, 2022|clinical, treatment|Comments Off on Slowing Down Progression of White Matter Hyperintensities by Antiplatelets — Too Good to Be True
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Article Commentary: “Effect of Moderate and Severe Persistent Hyperglycemia on Outcomes in Patients With Intracerebral Hemorrhage”

Ayush Agarwal, MD, DM, DNB
@drayushagarwal

Qureshi AI, Huang W, Lobanova I, Chandrasekaran PN, Hanley DF, Hsu CY, Martin RH, Steiner T, Suarez JI, Yamamoto H, Toyoda K. Effect of Moderate and Severe Persistent Hyperglycemia on Outcomes in Patients With Intracerebral Hemorrhage. Stroke. 2021.

The optimal management of hyperglycaemia in ICH continues to be a grey area with precise guidelines yet to be framed. This multi centric study sought to answer this query and evaluated the effect of persistent hyperglycaemia on the 90-day functional outcome (mRS) in patients with ICH, enrolled within 4.5 hours of symptom onset with hematomas<60ml and GCS>5. Moderate hyperglycaemia was defined as serum glucose concentrations between 140-180mg/dl and severe hyperglycaemia as beyond 180mg/dl. Blood sugar monitoring was done for 3 days (upon admission and successively at 24, 48 and 72 hours). 

The study found that moderate and severe persistent hyperglycaemia was associated with statistically significant worse outcomes (higher 90-day death or disability). These were mirrored in non-diabetic patients with ICH. However, statistical significance was not attained in the previously diagnosed diabetic group. The calculated risk was adjusted for Glasgow coma scale score, hematoma volume, intraventricular hemorrhage, hypertension, hyperlipidemia and cigarette smoking to rule out potential bias and confounding. No glycemic association with hematoma expansion was found.

By |March 8th, 2022|clinical|Comments Off on Article Commentary: “Effect of Moderate and Severe Persistent Hyperglycemia on Outcomes in Patients With Intracerebral Hemorrhage”
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Article Commentary: “Sex Differences in Plaque Composition and Morphology Among Symptomatic Patients With Mild-To-Moderate Carotid Artery Stenosis”

Mona Al Banna, MB BCh, Msc(Res)
@DrMonaAlBanna

van Dam-Nolen DHK, van Egmond NCM, Dilba K, Nies K, van der Kolk AG, Liem MI, Kooi ME, Hendrikse J, Nederkoorn PJ, Koodstaal PJ, et al. Sex Differences in Plaque Composition and Morphology Among Symptomatic Patients With Mild-to-Moderate Carotid Artery Stenosis. Stroke. 2022.

Data regarding outcome differences in carotid revascularization between males and females has been mixed. The authors of this study set out to explore whether carotid plaque composition and morphology differed between male and female stroke patients using an imaging-based approach whilst taking into account degree of plaque burden. The plaque characteristics that were evaluated included intra-plaque hemorrhage, lipid rich necrotic core, calcifications, thin or ruptured fibrous cap, plaque ulcerations and total plaque volume. The authors also explored combinations of plaque characteristics to evaluate the relationship between multiple vulnerable plaque phenotypes. Plaque characteristics were assessed with CTA and dedicated vessel wall MRI.

By |March 7th, 2022|clinical, diagnosis and imaging|Comments Off on Article Commentary: “Sex Differences in Plaque Composition and Morphology Among Symptomatic Patients With Mild-To-Moderate Carotid Artery Stenosis”
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ISC 2022 Session: Incidental Lacunes on Brain Imaging: How to Manage Them

Dixon Yang, MD

International Stroke Conference 2022
February 9–11, 2022

Session: Incidental Lacunes on Brain Imaging: How to Manage Them
Moderators: Dr. Christopher Lewandowski, Dr. Edip Gurol
Panelists: Dr. Hugo Aparicio, Dr. Eric Smith, Dr. Myriam Fornage, Dr. Jose Gutierrez

This invited symposium overviewed incidentally discovered lacunar infarcts on brain imaging. Dr. Aparicio from Boston University began by discussing prevalence and risk factors for incidental lacunar infarcts. Based on data from the Rotterdam Scan Study and Cardiovascular Health Study, “covert” brain infarcts (CBI) are not uncommon, making up about 1 in 10 in late middle age and 1 in 4 in the elderly, with an overall prevalence of 8-28% amongst predominantly non-Hispanic White and Asian study populations. Lacunar infarcts make up the majority of CBIs (83%) and share risk factors for stroke, especially age and hypertension; however, CBIs possibly have as high as 5-fold increased incidence when compared to stroke.

By |February 21st, 2022|clinical, Conference|Comments Off on ISC 2022 Session: Incidental Lacunes on Brain Imaging: How to Manage Them
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ISC 2022 Session: Thursday Main Event

Dixon Yang, MD

International Stroke Conference 2022
February 9–11, 2022

Session: Thursday Main Event
Moderators: Dr. Louise McCullough, Dr. Tudor Jovin
Speakers: Dr. Gary Rosenberg, Dr. Bradford Worrall, Dr. Suja Rajan, Dr. Ekaterina Barkradze, Dr. Angel Chamorro, Dr. Xin Cheng, Dr. Laurent Spelle

The Thursday Main Event of the International Stroke Conference included awards and a wide range of exciting late breaking science. To start, Dr. McCullough, ISC 2022 Program Chair from McGovern Medical School at UTHealth, presented the Thomas Willis Award to Dr. Rosenberg of the University of New Mexico. Dr. Rosenberg’s lecture discussed his work on identifying biomarkers in Binswanger’s disease, especially in the context of frequently co-existent Alzheimer’s disease. In particular, his work focused on matrix metalloproteinases (MMPs), which are involved in ischemic brain injury and VCI. The MarkVCID consortium explored angiogenic growth factors, cytokines, MMPs, and MRI biomarkers in Binswanger’s disease. Importantly, data from MarkVCID was used to create a Vascular Damage Score, which is a composite of MRI diffusion biomarkers and CSF AD pathology to help discern Binswanger’s disease and AD. Then, Dr. Worrall from the University of Virginia received the ISC Outstanding Stroke Research Mentor Award. He gave encouraging remarks on the importance of mentorship in training the next generation of clinicians and researchers.

By |February 21st, 2022|clinical, Conference|Comments Off on ISC 2022 Session: Thursday Main Event
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Article Commentary: “Contemporary Trends in the Nationwide Incidence of Primary Intracerebral Hemorrhage”

Ericka Samantha Teleg, MD

Bako AT, Pan A, Potter T, Tannous J, Johnson C, Baig E, Meeks J, Woo D, Vahidy FS. Contemporary Trends in the Nationwide Incidence of Primary Intracerebral Hemorrhage. Stroke. 2022.

This cross-sectional study highlights the importance of keeping track of nationwide changes in the intracerebral hemorrhage landscape based on demographic and geographic differences across the United States. While some regions globally do not have such resources to organize and structure the source of this database, this article provides a good template to do so because this is done at the national level.

The source for the data is the Nationwide Inpatient Sample (NIS), the largest publicly available all-payer in-hospital database in the United States. It represents over 90% of U.S. hospitalizations. The trend weights for pre-2012 NIS data were used to provide estimates comparable across pre- and post-2012 sample. The exclusion includes hospitalizations with concurrent diagnosis that is due to secondary intracerebral hemorrhage.

By |February 18th, 2022|clinical, Conference|Comments Off on Article Commentary: “Contemporary Trends in the Nationwide Incidence of Primary Intracerebral Hemorrhage”
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