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Diabetes, Intracranial Stenosis and Microemboli in Asymptomatic Carotid Stenosis

  • Thach D. Lam (a1), Stephanie Lammers (a1) (a2), Claudio Munoz (a3), Arturo Tamayo (a3) (a4) and J. David Spence (a1) (a3)...

Abstract

Background:

The risk of stroke in patients with asymptomatic carotid stenosis (ACS) is now so low that it is important to have methods to identify those patients most likely to benefit from intervention, or who may require special consideration in choice of medical therapy. We studied the prediction of stroke, death or transient ischemic attacks (stroke/death/TIA) in patients with ACS by intracranial arterial stenosis, and microemboli on transcranial Doppler (TCD), and the effect of diabetes mellitus on microemboli, intracranial stenosis and risk of events.

Methods:

Patients with ACS > 60% by Doppler ultrasound were recruited from the Stroke Prevention Clinic of University Hospital, London, Canada. All 339 participants underwent TCD for detection of intracranial stenosis and detection of microemboli, and carotid ultrasound to measure extracranial stenosis and total carotid plaque area. Participants were followed for three years, to determine the risk of stroke/death/TIA.

Results:

Stroke/death/TIA occurred in 38% of patients with microemboli versus 10% without (p=0.0001), and in 18% of patients with intracranial stenosis, versus 10% without (p=0.042). Diabetics were significantly more likely to have intracranial stenosis (45% vs. 29%, p =0.014), microemboli (38% vs. 10%, p <0.0001), and had significantly higher risk of stroke/death/TIA over three years (21% vs. 11% without; p=0.024). Survival free of stroke, TIA or death was significantly better without microemboli or intracranial stenosis (p<0.0001).

Conclusions:

Diabetes, microemboli and intracranial stenosis predicted higher risk of stroke, death or TIA than did extracranial stenosis or total plaque area; diabetics may need more intensive therapy.

Résumé: Contexte:

Le risque d'accident vasculaire cérébral (AvC) chez les patients porteurs d'une sténose carotidienne asymptomatique (SCA) est maintenant si faible qu'il est important d'établir des critères pour identifier les patients qui sont les plus susceptibles de bénéficier d'une intervention ou chez qui on doit porter une attention particulière au choix du traitement médical. nous avons examiné si la présence d'une sténose artérielle intracrânienne et de microembolies au Doppler transcrânien (DTC) étaient des facteurs de prédiction de l'AvC, du décès ou d'accès ischémiques transitoires (AIT) (AvC/décès/AIT) chez des patients porteurs d'une SCA ainsi que l'effet du diabète sur les microembolies, la sténose intracrânienne et le risque d'événements.

Méthode:

Nous avons recruté des patients présentant une SCA > 60% à l'échographie Doppler à la clinique de prévention de l'AvC à l'hôpital universitaire de London, en Ontario, au Canada. Les 339 participants ont subi un DTC pour la détection de la sténose intracrânienne et de microembolies et une échographie carotidienne pour mesurer la sténose extracrânienne et la surface totale de plaque. Les participants ont été suivis pendant 3 ans afin de déterminer le risque d'AvC/décès/AIT.

Résultats:

Un AvC/décès/AIT est survenu chez 38% des patients avec microembolies et chez 10% de ceux qui n'en avaient pas (p = 0,0001) ainsi que chez 18% des patients porteurs d'une sténose intracrânienne et chez 10% de ceux qui n'en avaient pas (p = 0,042). Les diabétiques étaient significativement plus susceptibles de présenter une sténose intracrânienne que ceux qui n'étaient pas diabétiques (45% par opposition à 29%; p = 0,014), des microembolies (38% par opposition à 10%; p < 0,0001) et ils avaient un risque significativement plus élevé d'AvC/décès/AIT au cours des trois années d'observation (21% par opposition à 11%; p = 0,024). La survie sans AvC, AIT ou décès était significativement meilleure sans microembolies ou sténose intracrânienne (p < 0,0001).

Conclusions:

Le diabète, les microembolies et la sténose intracrânienne prédisaient un risque plus élevé d'AvC, de décès ou d'AIT que la sténose extracrânienne ou la surface totale de plaque. Il se peut que les diabétiques aient besoin d'un traitement plus énergique.

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Copyright

Corresponding author

Stroke Prevention and Atherosclerosis Research Centre, Siebens-Drake Building, Robarts Research Institute, 1400 Western Road, London, Ontario, n6G 2v2, Canada. email: dspence@robarts.ca.

References

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