3D MRI Identifies Stroke Risk in Patients

With Diabetes
Marcia Frellick
November 30, 2015

CHICAGO Using 3-dimensional MRI to assess the carotid arteries of patients

with type 2 diabetes for intraplaque hemorrhage could help determine the risk for
stroke, new research suggests.

Intraplaque hemorrhage an indicator of advanced atherosclerotic disease

was found even in the absence of carotid artery stenosis, Tishan Maraj, MBBS,
an imaging analyst at Sunnybrook Research Institute in Toronto, reported here at
the Radiological Society of North America 2015 Annual Meeting

In their study, Dr Maraj and his colleagues focused on patients with diabetes
because the risk for worse outcome after stroke and the risk for mortality are
significantly higher in these patients than in those without diabetes.

Because patients with diabetes place a burden on the healthcare system, there is
an urgency to preventing complications, he explained.

The 159 patients involved in the study were part of the Low Glycemic Index for
Type 2 Diabetics trial being conducted by David Jenkins, MD, from St. Michael's
Hospital in Toronto. Average age of the patients was 63 years.

Low Glycemic Index for Type 2 Diabetics Trial

Intraplaque hemorrhage was detected with 3D MRI in at least one carotid artery
in 37 patients, and in five of these patients, it was detected in both arteries.

The investigators were surprised that the rate of intraplaque hemorrhage in at

least one carotid artery was as high as 23%, Dr Maraj told Medscape Medical
News.

The team then assessed vessel wall volume in patients with intraplaque
hemorrhage in one artery, and were taken aback by the correlation. When they
compared the two carotid arteries the one with and the one without intraplaque
hemorrhage the difference in vessel wall volume was significantly different.
Despite the same exposure to factors such as blood
sugar and blood pressure, intraplaque hemorrhage was
contributing to the greater vessel wall volume.

"This suggested that, despite the same exposure to factors such as blood sugar
and blood pressure, intraplaque hemorrhage was contributing to the greater
vessel wall volume," Dr Maraj said.

There are no treatments for intraplaque hemorrhage, but therapies such as

statins are known to improve vascular health and have been shown to decrease
vessel wall thickness.

Because of this association, patients with intraplaque hemorrhage are at

increased risk for advanced vascular disease. Therefore, "they should perhaps
undergo more intensive monitoring and potentially more intensive standard
therapy," Dr Maraj said. "Intervention at this stage of disease may stop the
disease progressing."

However, he pointed out, it is too early to recommend that patients with diabetes
undergo routine screening for intraplaque hemorrhage.

"Further follow-up of these patients is needed to see if intraplaque hemorrhage at

this early stage will lead to accelerated vascular disease resulting in vessel
narrowing and/or clinical events," he explained.

3D MRI promises to improve our ability to predict future stroke in patients with
carotid atherosclerosis, said Jin-Moo Lee, MD, PhD, from the Stroke and
Cerebrovascular Center at Barnes-Jewish Hospital and the Washington
University School of Medicine in St. Louis, Missouri.

"For the past 25 years, the only means to stratify stroke risk in patients with
carotid artery atherosclerosis was to measure the degree of narrowing in that
artery. This new technique adds another characteristic that may help stratify risk
by examining bleeding within the plaque," he toldMedscape Medical News.

The high proportion of patients with diabetes who had intraplaque hemorrhage
could take our understanding of diabetes and stroke risk to another level, he said.
But he agrees with Dr Maraj that more studies are necessary.

"It is known that patients with diabetes and narrowing of the carotid arteries have
a higher risk of stroke than patients without diabetes," Dr Lee explained.
"However, what remains to be seen is whether intraplaque hemorrhage will
improve our ability to predict future stroke in diabetic or other populations. That
will undoubtedly be one of the next studies that will be performed."

Dr Maraj and Dr Lee have disclosed no relevant financial relationships.

Radiological Society of North America (RSNA) 2015 Annual Meeting:

Abstract SSA17-05. Presented November 29, 2015.
Higher BMI Linked to Ischemic, Not
Hemorrhagic, Stroke
Pauline Anderson
September 09, 2016

A higher body mass index (BMI) is associated with an increased the risk for
ischemic stroke but lower odds of hemorrhagic stroke, a new study suggests.

"This was such a large study that we were able to look at the effect of BMI
separately on different stroke types not just on ischemic stoke, which everyone
knows is higher with increasing BMI, but also on different types of hemorrhagic
stroke, which although less common are more fatal," said study author Gillian K.
Reeves, PhD, professor, epidemiology, Cancer Epidemiology Unit, University of
Oxford, United Kingdom.

The findings, published online September 7 in Neurology, should not affect public
health recommendations related to target body weight, Dr Reeves told Medscape
Medical News.

The analysis included 1,277,129 women from the Million Women Study (mean
age at outset, 56.7 years), who were recruited at breast cancer screening centers
in England and Scotland between 1996 and 2001. About 1% of the women were
lost during follow-up that continued for a mean of 11.7 years.

Researchers used routinely collected National Health Service data and electronic
hospital records to gather information on fatal and nonfatal strokes.

During the follow-up, there were 20,549 first strokes, of which 9993 were
ischemic, 5852 were hemorrhagic (including intracerebral and subarachnoid),
and 4704 were of unspecified type.

BMI Categories

Researchers categorized patients into five groups according to BMI (kg/m 2): less
than 22.5, 22.5 to less than 25, 25 to less than 27.5, 27.5 to less than 30, and 30
or greater.
Higher BMI was associated with an increased risk for ischemic stroke. The
relative risk (RR) for ischemic stroke per 5-kg/m 2 increase in BMI was 1.23 (95%
confidence interval [CI], 1.20 - 1.26) after adjustment for age and region.

The RR was 1.21 (95% CI, 1.18 - 1.23) after additional adjustment for "deprivation" level, physical
exercise, alcohol intake, smoking, and height.

In contrast, the corresponding RR for hemorrhagic stroke decreased with

increasing BMI. It was 0.88 (95% CI, 0.85 - 0.91) after adjustment for age and
region and 0.89 (95% CI, 0.86 - 0.92) when also adjusting for the additional
confounders.

Results of a sensitivity analysis that included only hospital admissions with stroke
listed as the first diagnostic code did not differ substantially from the main
findings. The same was the case for analyses that excluded the first 5 years of
follow-up or patients with any prior ill health other than stroke and that adjusted
for history of cancer.

Lipid Levels
The higher risk for ischemic stroke with increased BMI might be related to such
risk factors as hypertension and diabetes. It may also have something to do with
changes in lipid levels, said Dr Reeves, which can drive atherosclerosis.

Although the link between BMI and hemorrhagic stroke risk appears to be less
clear, lipids could be involved here, too. Some evidence suggests that increasing
cholesterol levels are associated with decreased risk for hemorrhagic stroke, said
Dr Reeves.

The degree to which total or low-density lipoprotein cholesterol might moderate

the BMI relationship with hemorrhagic stroke could not be examined in the
current study but "would be of interest," said Kathryn Rexrode, MD, Division of
Preventive Medicine, Department of Medicine, Brigham and Women's Hospital,
Boston, Massachusetts, and Tatjana Rundek, MD, PhD, Department of
Neurology, University of Miami Miller School of Medicine, Florida, in
an accompanying editorial.

"Additional research on the mechanisms by which low BMI affects hemorrhagic

stroke risk is needed," they write.

The study findings are important in that they help researchers better understand
what causes some of the rarer types of stroke, said Dr Reeves.

"Now we know that actually being overweight and obese seems to be protective,"
she said. "Anything that helps our understanding of how the disease is actually
occurring is going to ultimately help with prevention."

Meta-Analysis

The researchers also carried out a systematic review and meta analysis that
included 12 studies: 5 from Europe, North America, and Australia and 5 from
Asia.

"We found that almost all the studies we looked at consistently showed a bigger
adiposity-associated relative risk for ischemic stroke than for hemorrhagic
stroke," said Dr Reeves.

However, there were some differences in the Asian studies. While there was a
22% increased risk for ischemic stroke for a 5-kg/m 2 increase in BMI among
European and North Americans, in Asians the risk was increased 35%.
Although it was clear that higher BMI increased the risk for ischemic stroke in
Asians, for hemorrhagic stroke, the relative risk was still slightly greater than 1,
albeit "a lot lower" than for ischemic stroke, said Dr Reeves.

The difference between studies conducted in Asia and those carried out in
western countries could be attributed to the "quite different" etiology of these
diseases in Asia, said Dr Reeves. "They tend to have a different distribution of
hemorrhagic and ischemic strokes."

Striking Finding

In their editorial, Dr Rexrode and Dr Rundek called the association of BMI with
both hemorrhagic and ischemic stroke in Asian populations "striking" in light of
the rising prevalence of obesity worldwide.

"Given the direct relationship with both ischemic and hemorrhagic stroke in Asian
populations, they will endure even greater effects of the scourge of rising
obesity."

The editorial writers noted that the Million Women Study was designed as a
breast cancer screening study and so is limited in gathering detailed stroke risk
factors. "BMI is a crude measure of obesity and does not take into account
fitness, nutritional status, or body fat distribution."

Results of this new study should not affect recommendations for ideal body
weights, Dr Reeves said. If patients want to improve their overall health and
reduce their risk for death, they should stay within the normal BMI range, she
said.

The study was funded by the UK Medical Research Council and Cancer
Research UK. The study authors and editorial writers have disclosed no relevant
financial relationships.

Neurology. Published online September 7, 2016. Abstract, Editorial