Risk Factor Stratification for Intracranial Stenosis in Taiwanese Patients With Cervicocerebral Stenosis

Yueh-Feng Sung, Jiunn-Tay Lee, Chia-Lin Tsai, Chun-Chieh Lin, Yaw-Don Hsu, Jiann-Chyun Lin, Chi-Ming Chu, Giia-Sheun Peng, Yueh-Feng Sung, Jiunn-Tay Lee, Chia-Lin Tsai, Chun-Chieh Lin, Yaw-Don Hsu, Jiann-Chyun Lin, Chi-Ming Chu, Giia-Sheun Peng

Abstract

Background: Intracranial stenosis (ICS) is a major determinant of ischemic stroke in Asians. We determined the clinical significance of different risk factors and the role of ICS in Taiwanese patients with varied distributions of cervicocerebral stenosis.

Methods and results: Presence of extracranial carotid stenosis (ECS, ≥70%) and ICS (>50%) was examined in 13 539 patients using ultrasonography and magnetic resonance angiography, respectively. Seven hundred thirty-three patients with non-ECS/ICS (n=372), isolated ICS (n=112), isolated ECS (n=121), or combined ECS/ICS (CEIS, n=128) were selected. Prevalence of ischemic stroke in each group was compared, and risk factors for stenosis were determined. The area under the receiver operating characteristic curve for each risk factor was calculated. Prevalence of ischemic stroke was highest in patients with CEIS (odds ratio 15.86; P<0.001), followed in decreasing order by those with isolated ICS (odds ratio 7.16; P<0.001), isolated ECS (odds ratio 1.77; P=0.011), and non-ECS/ICS. Multivariate logistic regression analysis revealed that hypertension, coronary artery disease, and smoking were risk factors for isolated ECS; hypertension, diabetes mellitus, coronary artery disease, and smoking were risk factors for isolated ICS; and diabetes mellitus, coronary artery disease, and smoking were risk factors for CEIS. Smoking, diabetes mellitus, and coronary artery disease were the greatest contributors to CEIS, isolated ICS, and isolated ECS, respectively.

Conclusions: CEIS was associated with higher odds of ischemic stroke compared with isolated ICS and isolated ECS. Smoking and diabetes mellitus, major determinants of CEIS and isolated ICS, should be targeted in therapeutic strategies to reduce the risk of ischemic stroke.

Keywords: atherosclerosis; carotid arteries; risk factors; stenosis; stroke.

© 2015 The Authors. Published on behalf of the American Heart Association, Inc., by Wiley Blackwell.

Figures

Figure 1
Figure 1
Study patient selection. *Age, sex, and examination dates were used as covariates to compute propensity score. CEIS indicates combined extracranial/intracranial stenosis; EC, extracranial carotid artery; IC, intracranial artery; IECS, isolated extracranial stenosis; IICS, isolated intracranial stenosis; MRI, magnetic resonance imaging; NEIS, nonextracranial/intracranial stenosis.
Figure 2
Figure 2
Odds ratio of ischemic stroke in IECS, IICS, and CEIS groups. The odds ratio of ischemic stroke was highest in the CEIS group (OR 15.86, 95% CI 6.81 to 36.91), followed in decreasing order by the IICS (OR 7.16, 95% CI 3.72 to 13.79), IECS (OR 1.77, 95% CI 1.14 to 2.74), and NEIS (reference) groups. CEIS indicates combined extracranial/intracranial stenosis; IECS, isolated extracranial stenosis; IICS, isolated intracranial stenosis; NEIS, nonextracranial/intracranial stenosis, OR odds ratio.
Figure 3
Figure 3
Receiver operating characteristic curve, demonstrating the associations of risk factors and prediction of IECS, IICS, and CEIS. A, CAD was the most predictive factor (highest AUC value) for IECS, followed in decreasing order by HTN and smoking. B, DM was the most predictive factor for IICS, followed in decreasing order by HTN, smoking, and CAD. C, Smoking was the most predictive factor for CEIS, followed in decreasing order by CAD and DM. AUC indicates area under the receiver operating characteristic curve; CAD, coronary artery disease; CEIS, combined extracranial/intracranial stenosis; DM, diabetes mellitus; HTN, hypertension; IECS, isolated extracranial stenosis; IICS, isolated intracranial stenosis.

References

    1. Qureshi AI, Caplan LR. Intracranial atherosclerosis. Lancet. 2014;383:984–998.
    1. De Silva DA, Woon FP, Lee MP, Chen CP, Chang HM, Wong MC. South Asian patients with ischemic stroke: intracranial large arteries are the predominant site of disease. Stroke. 2007;38:2592–2594.
    1. Moussouttas M, Aguilar L, Fuentes K, Anyanwu B, Manassarians H, Papamitsakis N, Shi Q, Visintainer P. Cerebrovascular disease among patients from the Indian subcontinent. Neurology. 2006;67:894–896.
    1. Sung YF, Tsai CL, Lee JT, Chu CM, Hsu CH, Lin CC, Peng GS. Reversal of ophthalmic artery flow and stroke outcomes in Asian patients with acute ischemic stroke and unilateral severe cervical carotid stenosis. PLoS One. 2013;8:e80675.
    1. Wong LK. Global burden of intracranial atherosclerosis. Int J Stroke. 2006;1:158–159.
    1. Sacco RL, Kargman DE, Gu Q, Zamanillo MC. Race‐ethnicity and determinants of intracranial atherosclerotic cerebral infarction. The Northern Manhattan Stroke Study. Stroke. 1995;26:14–20.
    1. Stenting of Symptomatic Atherosclerotic Lesions in the Vertebral or Intracranial Arteries (SSYLVIA): study results. Stroke. 2004;35:1388–1392.
    1. Collaborators NASCET . Beneficial effect of carotid endarterectomy in symptomatic patients with high‐grade carotid stenosis. N Engl J Med. 1991;325:445–453.
    1. Group ECSTC . Randomised trial of endarterectomy for recently symptomatic carotid stenosis: final results of the MRC European Carotid Surgery Trial (ECST). Lancet. 1998;351:1379–1387.
    1. Nishimaru K, McHenry LC Jr, Toole JF. Cerebral angiographic and clinical differences in carotid system transient ischemic attacks between American Caucasian and Japanese patients. Stroke. 1984;15:56–59.
    1. Feldmann E, Daneault N, Kwan E, Ho KJ, Pessin MS, Langenberg P, Caplan LR. Chinese‐White differences in the distribution of occlusive cerebrovascular disease. Neurology. 1990;40:1541–1545.
    1. Park KY, Chung CS, Lee KH, Kim GM, Kim YB, Oh K. Prevalence and risk factors of intracranial atherosclerosis in an asymptomatic Korean population. J Clin Neurol. 2006;2:29–33.
    1. Suwanwela NC, Chutinetr A. Risk factors for atherosclerosis of cervicocerebral arteries: intracranial versus extracranial. Neuroepidemiology. 2003;22:37–40.
    1. Leung SY, Ng TH, Yuen ST, Lauder IJ, Ho FC. Pattern of cerebral atherosclerosis in Hong Kong Chinese. Severity in intracranial and extracranial vessels. Stroke. 1993;24:779–786.
    1. Peng GS, Lee CC, Hsu CH, Lee JT, Lee FY, Tsao WL. Diagnostic assessment of carotid stenosis: comparison of color duplex ultrasonography with magnetic resonance angiography, cerebral angiography and carotid endarterectomy. J Med Ultrasound. 1996;4:174–179.
    1. MRC European Carotid Surgery Trial: interim results for symptomatic patients with severe (70‐99%) or with mild (0‐29%) carotid stenosis. European Carotid Surgery Trialists’ Collaborative Group. Lancet. 1991;337:1235–1243.
    1. Peng GS, Yin SJ, Cheng CA, Chiu SW, Lee JT, Lin WW, Lin JC, Hsu YD. Increased risk of cerebral hemorrhage in Chinese male heavy drinkers with mild liver disorder. Cerebrovasc Dis. 2007;23:309–314.
    1. Yao CT, Cheng CA, Wang HK, Chiu SW, Chen YC, Wang MF, Yin SJ, Peng GS. The role of ALDH2 and ADH1B polymorphism in alcohol consumption and stroke in Han Chinese. Hum Genomics. 2011;5:569–576.
    1. Wong KS, Ng PW, Tang A, Liu R, Yeung V, Tomlinson B. Prevalence of asymptomatic intracranial atherosclerosis in high‐risk patients. Neurology. 2007;68:2035–2038.
    1. Man BL, Fu YP, Chan YY, Lam W, Hui CF, Leung WH, Wong KS. Use of magnetic resonance angiography to predict long‐term outcomes of ischemic stroke patients with concurrent stenoses in Hong Kong. Cerebrovasc Dis. 2009;28:112–118.
    1. Lee SJ, Cho SJ, Moon HS, Shon YM, Lee KH, Kim DI, Lee BB, Byun HS, Han SH, Chung CS. Combined extracranial and intracranial atherosclerosis in Korean patients. Arch Neurol. 2003;60:1561–1564.
    1. Liu HM, Tu YK, Yip PK, Su CT. Evaluation of intracranial and extracranial carotid steno‐occlusive diseases in Taiwan Chinese patients with MR angiography: preliminary experience. Stroke. 1996;27:650–653.
    1. Tsai CL, Lee JT, Cheng CA, Liu MT, Chen CY, Hu HH, Peng GS. Reversal of ophthalmic artery flow as a predictor of intracranial hemodynamic compromise: implication for prognosis of severe carotid stenosis. Eur J Neurol. 2013;20:564–570.
    1. Kappelle LJ, Eliasziw M, Fox AJ, Sharpe BL, Barnett HJ. Importance of intracranial atherosclerotic disease in patients with symptomatic stenosis of the internal carotid artery. The North American Symptomatic Carotid Endarterectomy Trial. Stroke. 1999;30:282–286.
    1. Bos D, van der Rijk MJ, Geeraedts TE, Hofman A, Krestin GP, Witteman JC, van der Lugt A, Ikram MA, Vernooij MW. Intracranial carotid artery atherosclerosis: prevalence and risk factors in the general population. Stroke. 2012;43:1878–1884.
    1. Miyazawa N, Akiyama I, Yamagata Z. Analysis of incidence and risk factors for progression in patients with intracranial steno‐occlusive lesions by serial magnetic resonance angiography. Clin Neurol Neurosurg. 2007;109:680–685.
    1. Ritz K, Denswil NP, Stam OC, van Lieshout JJ, Daemen MJ. Cause and mechanisms of intracranial atherosclerosis. Circulation. 2014;130:1407–1414.
    1. Marzewski DJ, Furlan AJ, St Louis P, Little JR, Modic MT, Williams G. Intracranial internal carotid artery stenosis: longterm prognosis. Stroke. 1982;13:821–824.
    1. Diez‐Roux AV, Nieto FJ, Comstock GW, Howard G, Szklo M. The relationship of active and passive smoking to carotid atherosclerosis 12‐14 years later. Prev Med. 1995;24:48–55.
    1. Tell GS, Polak JF, Ward BJ, Kittner SJ, Savage PJ, Robbins J. Relation of smoking with carotid artery wall thickness and stenosis in older adults. The Cardiovascular Health Study. The Cardiovascular Health Study (CHS) Collaborative Research Group. Circulation. 1994;90:2905–2908.
    1. Ng M, Freeman MK, Fleming TD, Robinson M, Dwyer‐Lindgren L, Thomson B, Wollum A, Sanman E, Wulf S, Lopez AD, Murray CJ, Gakidou E. Smoking prevalence and cigarette consumption in 187 countries, 1980–2012. JAMA. 2014;311:183–192.
    1. Steinvil A, Sadeh B, Arbel Y, Justo D, Belei A, Borenstein N, Banai S, Halkin A. Prevalence and predictors of concomitant carotid and coronary artery atherosclerotic disease. J Am Coll Cardiol. 2011;57:779–783.
    1. Tanaka H, Nishino M, Ishida M, Fukunaga R, Sueyoshi K. Progression of carotid atherosclerosis in Japanese patients with coronary artery disease. Stroke. 1992;23:946–951.
    1. Durgan DJ, Bryan RM Jr. Cerebrovascular consequences of obstructive sleep apnea. J Am Heart Assoc. 2012;1:e000091 doi: .
    1. Ciccone MM, Sharma RK, Scicchitano P, Cortese F, Salerno C, Berchialla P, Frasso G, Sassara M, Carbone M, Palmiero P, Maiello M, Voelker DJ, Reddy HK, Federico F. Dolichocarotids: echo‐color Doppler evaluation and clinical role. J Atheroscler Thromb. 2014;21:56–63.

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