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Cardioembolic stroke:everything has changed

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Stroke & Vascular Neurology 2018年第2期3卷 76-83页

作者： J david spence Stroke Prevention and Atherosclerosis Research Centre Robarts Research InstituteWestern UniversityLondonOntarioCanada

Historically,because of the difficulty of using warfarin safely and effectively,many patients with cardioembolic stroke who should have been anticoagulated were instead given ineffective antiplatelet therapy(or no antithrombotic therapy).With the arrival of new oral anticoagulants that are not significantly more likely than aspirin to cause severe haemorrhage,everything has *** antiplatelet agents are much less effective in preventing cardioembolic stroke,it is now more prudent to anticoagulate patients in whom cardioembolic stroke is strongly *** advances include the recognition that intermittent atrial fibrillation is better detected with more prolonged monitoring of the cardiac rhythm,and that percutaneous closure of patent foramen ovale(PFO)may reduce the risk of ***,because in most patients with stroke and PFO the PFO is incidental,this should be reserved for patients in whom paradoxical embolism is likely.A high shunt grade on transcranial Doppler saline studies,and clinical clues to paradoxical embolism,can help in appropriate selection of patients for percutaneous *** patients with atrial fibrillation who cannot be anticoagulated,ablation of the left atrial appendage is an emerging *** is also increasingly recognised that high levels of homocysteine,often due to undiagnosed metabolic deficiency of vitamin B_(12),markedly increase the risk of stroke in atrial fibrillation,and that B vitamins(folic acid and B_(12))do prevent stroke by lowering ***,with regard to B_(12),methylcobalamin should probably be used instead of *** important considerations for judicious application of therapies to prevent cardioembolic stroke are discussed.

关键词： vitamin markedly likely

Diet for stroke prevention

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Stroke & Vascular Neurology 2018年第2期3卷 44-50页

作者： J david spence Stroke Prevention&Atherosclerosis Research Centre Robarts Research InstituteLondonOntarioCanada Neurology and Clinical Pharmacology University of Western OntarioLondonOntarioCanada

Lifestyle is far more important than most physicians *** changes in China that have resulted from increased prosperity are probably responsible for a marked rise in coronary risk in the past several decades,accelerating in recent *** of meat and eggs has increased,while intake of fruits,vegetables and whole grains has *** 2003 and 2013,coronary mortality in China increased 213%,while stroke mortality increased by 26.6%.Besides a high content of cholesterol,meat(particularly red meat)contains carnitine,while egg yolks contain *** are converted by the intestinal microbiome to trimethylamine,in turn oxidised in the liver to trimethylamine n-oxide(TMAO).TMAO causes atherosclerosis in animal models,and in patients referred for coronary angiography high levels after a test dose of two hard-boiled eggs predicted increased cardiovascular *** strongest evidence for dietary prevention of stroke and myocardial infarction is with the Mediterranean diet from Crete,a nearly vegetarian diet that is high in beneficial oils,whole grains,fruits,vegetables and *** at risk of stroke should avoid egg yolk,limit intake of red meat and consume a diet similar to the Mediterranean diet.A crucial issue for stroke prevention in China is reduction of sodium *** changes,although difficult to implement,represent an important opportunity to prevent stroke and have the potential to reverse the trend of increased cardiovascular risk in China.

关键词： prevention intake mortality

China Stroke Statistics 2019: a wealth of opportunities for stroke prevention

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Stroke & Vascular Neurology 2020年第3期5卷 240-241页

作者： J david spence Stroke Prevention & Atherosclerosis Research Centre Western University Robarts Research Institute London Ontario Canada

The China Stroke Statistics published in this issue of the journal1 represent an enormous *** included data on 3010204 patients who had a stroke admitted in 2018 to 1853 tertiary care hospitals and compiled data from multiple sources on stroke and stroke risk factors in *** authors and the huge team of workers who must have compiled the statistics are to be commended on this enormous *** the report is a wealth of data on what is wrong in China to cause such a high risk of stroke but also a wealth of opportunity to make a *** reason this is so important is that~80%of strokes are preventable.

关键词： prevention admitted journal

Appropriate management of asymptomatic carotid stenosis

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Stroke & Vascular Neurology 2016年第2期1卷 64-71页

作者： J david spence Hongsong Song Guanliang Cheng Robarts Research Institute Western UniversityLondonOntarioCanada Peking University Third Hospital BeijingThe People’s Republic of China Huai’an First People’s Hospital Nanjing Medical UniversityHuai’anThe People’s Republic of China

With modern intensive medical therapy,the annual risk of ipsilateral stroke in patients with asymptomatic carotid stenosis(ACS)is now down to∼0.5%.Despite this,there is a widespread practice of routine intervention in ACS with carotid endarterectomy(CEA)and stenting(CAS).This is being justified on the basis of much higher risks with medical therapy in trials conducted decades ago,compared with lower risks of intervention in recent trials with no medical *** extrapolations are *** recent trials have shown that after subtracting periprocedural risks the outcomes with CEA and CAS are now comparable to medical therapy,the periprocedural risks still far outweigh the risks with medical *** the asymptomatic carotid trial(ACT)1 trial,the 30-day risk of stroke or death was 2.9%with CAS and 1.7%with *** the CREST trial,the 30-day risk of stroke or death among asymptomatic patients was 2.5%for stenting and 1.4%for ***,intensive medical therapy is much safer than either CAS or *** only patients with ACS who should receive intervention are those who can be identified as being at high *** best validated method is transcranial Doppler embolus *** approaches in development for identifying vulnerable plaques include intraplaque haemorrhage on MRI,ulceration and plaque lucency on ultrasound,and plaque inflammation on positron emission tomography/*** medical therapy for ACS includes smoking cessation,a Mediterranean diet,effective blood pressure control,antiplatelet therapy,intensive lipid-lowering therapy and treatment with B vitamins(with methylcobalamin instead of cyanocobalamin),particularly in patients with metabolic B12 deficiency.A new strategy called‘treating arteries instead of risk factors’,based on measurement of carotid plaque volume,is promising but requires validation in randomised trials.

关键词： carotid asymptomatic stenosis

How to identify which patients with asymptomatic carotid stenosis could benefit from endarterectomy or stenting

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Stroke & Vascular Neurology 2018年第2期3卷 92-100页

作者： Kosmas I Paraskevas Frank J Veith J david spence Department of Vascular and Endovascular Surgery Royal Free HospitalLondonUK Department of Vascular Surgery New York University Langone Medical CenterNew YorkUSA Department of Vascular Surgery Cleveland ClinicClevelandOhioUSA Stroke Prevention&Atherosclerosis Research Centre Robarts Research InstituteWestern UniversityLondonCanada

Offering routine carotid endarterectomy(CEA)or carotid artery stenting(CAS)to patients with asymptomatic carotid artery stenosis(ACS)is no longer considered as the optimal management of these *** suboptimal,however,is the policy of offering only best medical treatment(BMT)to all patients with ACS and not considering any of them for prophylactic *** the last few years,there have been many studies aiming to identify reliable predictors of future cerebrovascular events that would allow the identification of patients with high-risk ACS and offer a prophylactic carotid intervention only to these patients to prevent them from becoming *** patients with ACS should receive *** present article will summarise the evidence suggesting ways to identify these high-risk asymptomatic individuals,namely:(1)microemboli detection on transcranial Doppler,(2)plaque echolucency on Duplex ultrasound,(3)progression in the severity of ACS,(4)silent embolic infarcts on brain CT/MRI,(5)reduced cerebrovascular reserve,(6)increased size of juxtaluminal hypoechoic area,(7)identification of intraplaque haemorrhage using MRI and(8)carotid *** evidence suggests that approximately 10%-15%of patents with asymptomatic stenosis might benefit from intervention;this will become more clear after publication of ongoing studies comparing stenting or endarterectomy with best medical *** the meantime,no patient should be offered intervention unless there is evidence of high risk of ipsilateral stroke,from modalities such as those discussed here.

关键词： patients carotid stenosis

Blood pressure gradients in cerebral arteries:a clue to pathogenesis of cerebral small vessel disease

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Stroke & Vascular Neurology 2017年第3期2卷 108-117页

作者： Pablo J Blanco Lucas O Müller J david spence National Laboratory for Scientific Computing PetrópolisBrazil National Institute of Science and Technology in Medicine Assisted by Scientific Computing INCT-MACCPetrópolisBrazil Stroke Prevention&Atherosclerosis Research Centre Robarts Research InstituteWestern UniversityLondon

rationale The role of hypertension in cerebral small vessel disease is poorly *** the base of the brain(the‘vascular centrencephalon’),short straight arteries transmit blood pressure directly to small resistance vessels;the cerebral convexity is supplied by long arteries with many branches,resulting in a drop in blood *** small vessel disease(lipohyalinosis)causes the classically described lacunar infarctions at the base of the brain;however,periventricular white matter intensities(WMIs)seen on MRI and WMI in subcortical areas over the convexity,which are often also called‘lacunes’,probably have different *** We studied pressure gradients from proximal to distal regions of the cerebral vasculature by mathematical *** and results Blood flow/pressure equations were solved in an Anatomically Detailed Arterial Network(ADAN)model,considering a normotensive and a hypertensive *** parameters were suitably modified to account for structural changes in arterial vessels in the hypertensive *** predict a marked drop in blood pressure from large and medium-sized cerebral vessels to cerebral peripheral *** blood pressure in the brachial artery is 192/113 mm Hg,the pressure in the small arterioles of the posterior parietal artery bed would be only 117/68 mm *** the normotensive case,with blood pressure in the brachial artery of 117/75 mm Hg,the pressure in small parietal arterioles would be only 59/38 mm *** These findings have important implications for understanding small vessel *** marked pressure gradient across cerebral arteries should be taken into account when evaluating the pathogenesis of small WMIs on *** small vessel disease,affecting the arterioles at the base of the brain should be distinguished from small vessel disease in subcortical regions of the convexity and venous disease in the periventricular white matter.

关键词： cerebral Blood pathogenesis

Association of homocysteine and smoking with cerebral microemboli in patients with mechanical heart valves:a transcranial Doppler study

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Stroke & Vascular Neurology 2017年第4期2卷 199-204页

作者： Alicia Mattia M Reza Azarpazhooh Claudio Munoz Chrysi Bogiatzi Mackenzie A Quantz J david spence Stroke Prevention and Atherosclerosis Research Centre Robarts Research InstituteWestern UniversityLondonOntarioCanada Department of Neurology McMaster UniversityHamiltonOntarioCanada Division of Epidemiology and Biostatistics Western UniversityLondonOntarioCanada Division of Neurology Western UniversityLondonOntarioCanada Division of Cardiac Surgery Western UniversityLondonOntarioCanada Division of Clinical Pharmacology Western UniversityLondonOntarioCanada

Objectives Microembolic signals(MES)on transcranial Doppler(TCD)predict stroke and cognitive *** levels of total homocysteine(tHcy),a prothrombotic factor,are higher in patients with microemboli in carotid stenosis and in patients with paradoxical *** this study we assessed the association between the level of tHcy and the number of MES in patients with mechanical heart valves(MHVs).Methods TCD monitoring was performed to detect MES before and after breathing 100% oxygen and repeated every 2-4 weeks up to six *** Twenty-five patients with MHVs(mean age:63.60±10.15 years)participated in this study;15 were men(66.47±7.25 years)and 10 were women(59.30±12.60 years).In total,there were 126 study *** multiple regression,higher tHcy was associated with more MES in both preoxygenation(OR 1.34(95%CI 1.07 to 1.68,P=0.009))and postoxygenation(OR 1.40(95% CI 1.07 to 1.83,P=0.01))*** smoking and the length of time between the operation and monitoring also correlated with a higher number of MES before and after breathing oxygen,particularly in *** Higher tHcy and smoking were associated with a higher MES count in both preoxygenation and postoxygenation *** smoking can be stopped and hyperhomocysteinaemia is treatable,these are clinically important findings.

关键词： patients assessed cerebral

Recent Advances in Stroke Prevention

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中华脑血管病杂志（电子版） 2020年第1期14卷 1-12页

作者： J.david spence Neurology&Clinical Pharmacology Western University/Stroke Prevention&Atherosclerosis Research CentreRobarts Research Institute

Stroke is the most important cause of death and disability in China,and most strokes(~80-90%)are *** advances in a number of measures to reduce stroke are discussed in this narrative review,including smoking cessation,a Mediterranean pattern of eating,salt restriction,B vitamins to lower homocysteine,antiplatelet therapy,anticoagulants and the management of patent foramen ovale and carotid *** of homocysteine with B vitamins does prevent stroke,but patients with variants of MTHFR require higher doses of folic acid,and because of harm from cyanocobalamin among persons with renal impairment,we should use methylcobalamin or oxocobalamin *** resistance appears to be due to enteric coating,and>50% of Chinese have a reduced response to clopidogrel because of variants of CYP2C19,required to convert the prodrug to its active *** acting oral anticoagulants(DOACs)have revolutionized anticoagulation;important differences among the DOACs are *** closure of patent foramen ovale(PFO)does reduce the risk of stroke,but in most patients with stroke and PFO the PFO is incidental;it is important to identify the subgroup in whom paradoxical embolism was the probable cause of the *** patients with PFO would be better treated with anticoagulants because of the risk of pulmonary *** stenting carries a higher risk in older patients,and most patients with asymptomatic carotid stenosis would be better treated with intensive medical therapy than with either stenting or endarterectomy;the few who could benefit can be identified.

关键词： vitamin doses instead

Carotid plaque burden is associated with higher levels of total homocysteine

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Stroke & Vascular Neurology 2017年第1期2卷 40-40页

作者： J david spence Stroke Prevention & Atherosclerosis Research Centre Robarts Research Institute Western University London Ontario Canada.

There are several problems with the report of Li et al.1 They studied sex differences,not gender differences.2 They referred to carotid intima-media thickness(IMT)as atherosclerosis;it is not,and plaque burden is a much stronger predictor of cardiovascular risk than IMT.3 They referred to levels of homocysteine(Hcy),but almost certainly what they measured was total homocysteine(tHcy),which includes homocysteine,its dimer homocystine and mixed homocysteine/cysteine disul-fide.4 Their conclusion that homocysteine levels are not associated with carotid atherosclerosis is invalid,because(a)they did not measure atherosclerosis;they only identified the presence or absence of plaque and(b)the range of homocysteine levels they studied was above the threshold for increased plaque with increasing levels of tHcy.

关键词： homocysteine al. atherosclerosis