The association of antihypertensive agents with MRI white matter findings and with Modified Mini-Mental State Examination in older adults.

OBJECTIVES: To examine the association of antihypertensive regimen with magnetic resonance imaging (MRI) white matter hyperintensity and with cognitive impairment in older adults. DESIGN: Cross-sectional study. SETTING: The Cardiovascular Health study, an observational prospective cohort study of risk factors for coronary heart disease and stroke in men and women 65 years of age and older. PARTICIPANTS: 1268 men and women with pharmacologically treated hypertension. MEASUREMENTS: Information on medication use, medical history, and health habits was collected at clinic examinations. Participants completed the Modified Mini-Mental State Examination (3MS) and underwent MRI examination. Without clinical information, study neuroradiologists assigned an overall grade of white matter signal intensity on MRI on a scale from 0 (no findings) to 9 (extensive findings). RESULTS: Adjusted mean white matter grade was higher for users of calcium channel blockers (2.59, P = .007) and users of loop diuretics (2.60, P = .015) than for users of beta blockers (2.12). The association was present for both dihydropyridine and non-dihydropyridine calcium channel blockers. Adjusted mean 3MS scores were lower for users of calcium channel blockers (89.6, P < .002), especially dihydropyridines, and users of loop diuretics (89.7, P < .006) than for users of beta blockers (92.3). No statistically significant association could be shown for users of other drug regimens, including thiazides and ACE inhibitors. CONCLUSION: In this study, users of antihypertensive regimens which included calcium channel blockers or loop diuretics had more severe white matter hyperintensity on MRI and worse performance on 3MS than users of beta blockers.

Diurnal blood pressure variations and onset of subarachnoid haemorrhage: a population-based study.

OBJECTIVES: To analyse the association between time of onset of subarachnoid haemorrhage and diurnal blood pressure variations of ambulant normo- and hypertensive subjects. DESIGN: Retrospective, population-based study. SETTING: The population (246,000) of the Health Care District of Central Finland. PATIENTS: During 1980-1987 a total of 332 subjects in the study population had their first subarachnoid haemorrhage. The hour of onset could be obtained for 287 patients, and these form the basis of the present study. RESULTS: The onset of subarachnoid haemorrhage occurred significantly more often during the waking hours than during the night. The correlation between the hourly numbers of patients suffering a haemorrhage and the corresponding mean systolic and diastolic blood pressure values of ambulant normo- and hypertensive subjects was highly significant (r = 0.88, P < 0.001). The results were similar when the 224 patients with proved aneurysmal bleed were analysed separately (r = 0.79-0.85, P < 0.001). CONCLUSIONS: The diurnal blood pressure variations of ambulant normo- and hypertensive subjects, especially the transient blood pressure peaks reaching much higher levels of pressure during the waking hours than during the night, may be crucial in determining the time of rupture of a critically weakened aneurysm wall.

Cerebral infarction verified by cranial computed tomography and prognosis for survival following transient ischemic attack.

Of 564 consecutive patients with transient ischemic attack, 350 (62%) had cranial computed tomography performed. Except for date of admission and smoking history, there were few differences between the patients evaluated with computed tomography and the 214 who were not. Cerebral infarcts were found in 59 (17%) of the 350 tomographic evaluations. Previous clinically diagnosed stroke, older age, and male sex were all significantly associated with the occurrence of tomographically verified infarcts (p less than 0.05). After controlling for stroke history and other important covariates, patients with tomographically verified infarcts had significantly shorter survival times than did patients without evidence of infarction on computed tomography (p = 0.035). Thus, cranial computed tomography findings appear to have important prognostic value for estimating survival following transient ischemic attack.

Extracranial carotid atherosclerosis in patients with and without transient ischemic attacks and coronary artery disease.

We examined the extent of extracranial carotid atherosclerosis as evaluated by a B-mode ultrasound score in four groups of hospitalized patients: hospital controls free of both cerebrovascular symptoms and coronary atherosclerosis (HC, n = 245); patients with coronary atherosclerosis but without cerebrovascular symptoms (CAD, n = 382); patients with transient ischemic attacks but asymptomatic for coronary atherosclerosis (TIA, n = 107); and patients having both transient ischemic attacks and symptomatic coronary events (TIA + CAD, n = 39). The unadjusted B-mode scores were lowest for the HC group, intermediate for the CAD group, and highest for the TIA or TIA + CAD groups (no difference between these two groups). However, after adjustment for age (or age and other risk factors), we could find no significant differences among the CAD, TIA, and TIA + CAD groups, while the HC group had significantly lower adjusted scores. These data suggest that 1) accentuated development of carotid atherosclerosis is associated with both TIA and CAD and 2) the apparent differences in extracranial carotid atherosclerosis between coronary and cerebrovascular patients are partly attributable to differences in risk factor profiles (most notably age). The potentially accentuated rate of development of extracranial atherosclerosis in patients with CAD mandates a low threshold for cerebrovascular evaluation in CAD patients.

Correlation of carotid bruits and carotid atherosclerosis detected by B-mode real-time ultrasonography.

The extent of carotid atherosclerosis evaluated by B-mode real-time ultrasound and the presence of bruits established by carotid phonoangiography were determined in 1,107 patients. Unilateral bruit was associated with increased atherosclerosis compared with no bruit (p less than or equal to 0.0001). However, there was no association between laterality of the bruit and the degree of atherosclerosis (p = 0.66). There was marginal evidence that patients with bilateral bruits had more severe atherosclerosis than patients with unilateral bruit (p = 0.046). The relation between bruit and atherosclerosis categorized by B-mode ultrasound was not sufficient to reliably predict the presence or absence of disease in an individual patient, though the presence of a bruit should be viewed as a risk factor for, or an indicator of, increased risk of systemic atherosclerosis.

The effect of radiation on carotid arteries. A review article.

The effects of irradiation on blood vessels supplying the brain are reviewed. Short-term and long-term effects on large arteries result in an atheroscleroticlike disorder. The response may have a latency up to 20 years before the onset of symptoms and signs. This delay is probably related to the diameter of the irradiated artery; the interval is longer for larger arteries. However, it is possible that the apparent injury to the large arteries is in fact due to occlusion of the vasa vasorum because the microvasculature is especially vulnerable to radiation damage.

Cerebral infarction in patients with transient ischemic attacks.

Cranial computed tomography of 284 patients with transient ischemic attacks (TIAs) and without previous stroke was evaluated. The sample population included patients with carotid and/or vertebrobasilar TIAs. Computed tomography revealed cerebral infarction in 34 patients, including 5 with multiple infarctions. The lesion location was consistent with TIA symptoms in 16 patients. In another 16 patients, however, the lesion location did not correspond to the TIA symptoms; these lesions were attributed to previous silent infarctions. Two patients with multiple infarctions had both symptomatic and asymptomatic lesions. Age and carotid stenosis were each significantly related to an increased chance of detecting cerebral infarction (either symptomatic or asymptomatic). No significant relationship between race, gender, hypertension, diabetes, cardiac disease, or smoking and the incidence of infarction was found by either univariate or multivariate analyses.

Cause specific mortality following cerebral infarction.

Mortality from four causes (index stroke, subsequent stroke, cardiac disease and non-cardiovascular causes) was examined during a 5 year follow-up of 1694 cerebral infarction patients admitted to 25 community hospitals between 1969 and 1973. The hazard for mortality from the index stroke was high initially, but declined to a negligible level by 6 months post-stroke. In contrast, hazards for mortality from subsequent strokes, cardiac diseases and non-cardiovascular causes each peaked midway through the first year, declined during the remainder of that year, and then increased in the latter part of the follow-up. Proportional hazards analysis indicated that advanced age and increased stroke severity were the only factors significantly related to increased risk from each of the four causes of death. Other risk factors were significant only for one or two select causes of death. White patients were less likely to die from subsequent strokes, but more likely to die from cardiac diseases, than were non-white patients (primarily blacks). Males were more likely to die from both the index stroke and non-cardiovascular causes than females. A history of cardiac disease increased the risk of death from both the index stroke and from future cardiac events, while a history of hypertension or diabetes increased the risk of death from non-cardiovascular causes, and a history of previous stroke increased the risk of death from subsequent stroke.