International Journal of Current Research and Review
ISSN: 2231-2196 (Print)ISSN: 0975-5241 (Online)
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IJCRR - vol 06 issue 01, January, 2014

Pages: 72-78

Date of Publication: 30-Nov--0001


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ISCHEMIC STROKE: RELEVANCE OF MAGNETIC RESONANCE ANGIOGRAPHY (MRA) FINDINGS AND CORRELATING THE CHANGES WITH VARIOUS CONVENTIONAL AND NONCONVENTIONAL RISK FACTORS

Author: Ravinder Kumar, Jyoti

Category: Healthcare

Abstract:Objective: This study aims to correlate the magnetic resonance angiography (MRA) changes in ischemic stroke (IS) patients to identify various conventional and nonconventional risk factors. Material and Methods: Total 100 cases with Ischemic stroke ( IS) were clinically evaluated including body mass index, dietary habits, and family history of stroke. MR imaging, MRA, and testing for blood sugar and lipid profile were carried out. Results: The MRA abnormality positively correlated with low density lipids (LDL), Cholesterol and diabetes, and negatively with alcohol consumption and high density lipids (HDL). Out of total 100 patients, 50% were normal, 35% had significant stenosis and 15% had total occlusion. Males have equal incidence of Intracranial stenoses (ICS) and Extracranial stenoses (ECS) but Females are more likely to have ICS. The patients having age < 60yrs more likely to have intracranial stenosis and those having age >60yrs are more likely to have extracranial stenosis. Middle cerebral artery (MCA) was the most common arterial territory involved in all stages of infarct. Posterior cerebral artery (PCA) was the next common arterial territory to be involved. Single stenoses are more common in intracranial atherosclerosis (ICAs) and multiple stenoses are more common in extracranial atherosclerosis (ECAs). Conclusion: MRA is a robust imaging technique for determining the severity of stenosis, vascular occlusion, and collateral flow and in the determination of stroke etiologies.

Keywords: Extracranial, Ischemic stroke, Lipid profile, Magnetic resonance angiography, Stenosis.

Full Text:

INTRODUCTION

The term “stroke” according to WHO is defined as rapidly developing clinical symptoms and or signs of focal and at times global cerebral functions with symptoms lasting more than 24 hours or leading to death, with no apparent cause other than that of vascular origin. A focal neurologic deficit less than 24 hours is defined as a transient ischemic attack (TIA) and when it exceeds 24 hours and resolves within one week, termed reversible ischemic neurologic deficit (RIND). Approximately 75% of all strokes are ischemic in origin. Out of these, four fifth by atherosclerosis and about one fifth cases by thromboembolism from heart. Very few cases of ischemic stroke can also result from fibro muscular dysplasia, intracranial dissection, Moya-Moya disease, or vasculitis (Takayasu disease, giant cell arteritis, collagen vascular diseases, systemic necrotizing vasculitis, granulomatous angiitis of the nervous system). A reduction in blood flow that lasts for several seconds or minutes causes Cerebral ischemia and if the cessation of blood flow lasts for more than 5 minutes „infarction of brain? tissue results. Risk factors for carotid disease are : age, cigarette smoking, alcohol consumption, hyperlipidemia, hypercholesteremia, hypertension, diabetes mellitus, obesity, type A personality, insufficient physical exercise, newer risk factor like homocystiene and lipoprotein (a) etc., contributes to development of plaque formation and subsequent narrowing of the lumen of the vessels. Angiography, especially the three-dimensional time-of-flight technique, is very helpful noninvasive diagnostic tool for early identification of suspected steno-occlusive disease either extracranial or intracranial. In the studies of Masaryk2 et al and Heiserman1 et al, the findings of MRA and conventional angiography were well correlated as about 80% to 98% in diagnosis of ECCA diseases. Overall sensitivities of 85% and 88% and specificities of 96% and 97% for ICCA and middle cerebral artery, respectively, have been reported.1,2 However the studies regarding the Indians are incomplete. Our purpose is to evaluate the location and distribution of severe atherosclerotic stenosis in Indian patients by using MR angiography and to correlate the changes with various risk factors. 

MATERIALS AND METHODS

A total of 100 patients belonging to all age and sex groups with H/O focal neurological deficit with suspected stroke underwent MR angiography study by using 3-D time of flight technique on a 1.5T machine with a standard head coil. According to clinical history all the extracranial angiography findings were grouped into symptomatic side and contralateral side. Results that were 50% were recorded as significant stenosis

Pre Procedural Work up of patients: A detailed history has been taken from all patients and they underwent a thorough neurological examination and designated as having (l)TIA (2) RIND (3) Stroke in evolution (4) Completed Stroke Patients are designated as having ischemic stroke by following criteria: 1. Patients have stroke as indicated by clinical examination, and CT scan / MR document the presence of infarction. 2. Patients have stroke as indicated by clinical examination, with a normal CT scan / MRI study (hemorrhage ruled out). Scanning parameters taken are shown in Table I. H / O alcohol consumption recorded. Other Investigations Along with baseline investigations, blood sugar and lipid profile was done to estimate LDL, HDL and Cholestrol levels. RESULTS In all the patients, Vessels are classified as (1) Normal or clinically non significant stenosis (ie, 50% stenosis), (3) Total occlusion on the symptomatic side and the contralateral side respectively. Table II shows that patients having age 60 yrs are more likely to have extracranial stenosis. Also Males have equal incidence of ICS and ECS but Females are more likely to have ICS. MCA was the most common arterial territory involved in all stages of infarct. (Figure I andIII). PCA was the most common arterial territory to be involved next to MCA. ACA and MCA both were involved in 6% of cases. (Figure II andIV). The commonest presenting symptom in patients with cerebral infarction was hemiparesis (52.6%), right being slightly more common (30.7%) than left (21.9%)

Headache was seen in 17.5% cases. Cerebellar symptoms were noted in 13.2% of cases. Monoparesis was found in 9% of cases. Single stenoses are more common in ICAs and multiple stenoses are more common in ECAs. However ICAs are more likely to have stenoses. Table III shows that increased LDL, Cholesterol and blood sugar level and decreased HDL level are associated with increased frequency of stenoses.

DISCUSSION

The present study was undertaken to evaluate the location and distribution of vascular lesions in cerebrovascular steno-occlusive diseases in Indian patients with the use of Magnetic Resonance Angiography. A total of 100 patients were included in the study. Out of total, 50% are either normal or having clinically non-significant stenosis (50% stenosis), 15% are having total occlusion of the vessel. In this study, 45 patients are having age 60yrs. Out of these, 20(20%) have ECS and 15(15%) have ICS. So, the patients having age 60yrs are more likely to have extracranial stenosis. These findings correlate well with G. Neil Thomas et al19 . The study group comprised of 65 males and 35 females. Out of these, 50 males and 15 females have stenotic lesions. Males have equal incidence of ICS (25%) and ECS (25%) but Females are more likely to have ICS(10% ICS and 5% ECS). Similar findings were observed in study done by Tatjana Rundek18 . The commonest presenting symptom was hemiparesis in 60(52.6%) patients, right sided being slightly more common (30.7%) than the left (21.9%). Truwit et al and Winer et al also reported a similar incidence of hemiparesis in their studies. Monoparesis was seen in 10 (9%) patients, headache in 20(17.5%) patients and cerebellar symptoms were noted in 15(13.2%) patients. MCA was the most common arterial territory to be involved in all stages of infarcts 34(34%). PCA was the next most common 10(10%) to be involved.These findings correlate well with study done by Hossein Zarei et al15 . The present study shows single stenoses are more common in ICAs (25%) and multiple stenoses are more common in ECAs (15%). Findings were similar to the study done by Dae Chul Suh et a116 . The study shows increased LDL (>l30mg/dl), Cholesterol level (>200mg/dl), blood sugar (> 120 mg/dl) and decreased HDL (<30mg/dl) level are associated with increased frequency of stenoses. Similar findings were noted by Ellisiv B. Mathiesen17 et al and G. Neil Thomas et al19

CONCLUSION

In acute stroke cases, the study of cerebral vasculature is very important for management of it, the usefulness of MRA is proved for determine vascular occlusion, collateral flow and the severity of stenosis. Intracranial proximal stenoses and occlusions are accurately evaluated by threedimensional TOF MRA and for determining collateral blood flow patterns in the circle of Willis, Two-dimensional PC MRA is more useful.MRA is also helpful in the recognition of stroke aetiologies such as dissection, fibromuscular dysplasia, vasculitis, and moya moya. The relatively insensitiveness of MRA to detect of the stenoses in distal intracranial vessels is also useful for development of new MR software and hardware. Also correlation of lipid profile with stroke may be used in the future to monitor response to lipid-lowering drug therapy.

 

References:

REFERENCES

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2. Masaryk AM, Ross JS, DiCello MC, Modic MT, Paranandi L, Masaryk TJ. 3D TOE MR Angiography of carotid bifurcation: potential and limitation as screening examination. Radiology, 1991; 1 79:797-804.

3. S Warach, W Li, M Ronthal and RR Edelman Acute cerebral ischemia: evaluation with dynamic contrast-enhanced MR imaging and MR angiography Radiology, Vol 182, 41-47.

4. Yang Janice J. ; Hill Michael D. ; Moorish William F. Hudon Mark E. ; Barber Philip A.; Demchuk Andrew M. Sevick Robert J. ; Frayne Richard. Comparison of Pre- and postcontrast 3D time-of-flight MR angiography for the evaluation of distal intracranial branch occlusions in acute ischemic stroke. Amer journal of neuroradiology 2002, vol. 23, no.4, pp. 557- 567.

5. Nicoletta Anzalone, MD, Francesco Scomazzoni, MD, Renata Castellano, MD, Laura Strada, MD, Claudio Righi, MD, Letterio S. Politi, MD, Miles A. Kirchin, PhD, Roberto Chiesa, MD and Giuseppe Scotti, MD Carotid Artery Stenosis: Intraindividual Correlations of 3D Time-of-Flight MR Angiography, Contrast-enhanced MR Angiography, Conventional DSA, and Rotational Angiography for Detection and Grading Radiology 2005;236:204-213.

6. Michel Nonent, MD, Jean-Michel Serfaty, MD, PhD, Norbert Nighoghossian, MD, Francois Rouhart, MD, Laurent Derex, MD.Concordance Rate Differences of 3 Noninvasive Imaging Techniques to Measure Carotid Stenosis in Clinical Routine Practice Stroke. 2004; 35:682.

7. Luca Remondaa, Pascal Sennb, Alain Barthb, Marcel Arnoldc, Karl Olof Lovblada and Gerhard Schroth Contrast-Enhanced 3D MR Angiography of the Carotid Artery: Comparison with Conventional Digital Subtraction Angiography .American Journal of Neuroradiology 23:213-219, February 2002.

8. Mirco Cosottini, MD; Alessandro Pingitore, MD, PhD; Michele Puglioli, MD; Maria Chiara Michelassi, MD; Giancarto Lupi, M DContrast-Enhanced Three-Dimensional Magnetic Resonance Angiography of Atherosclerotic Internal Carotid Stenosis as the Noninvasive Imaging Modality in Revascularization Decision Making. Stroke. 2003;34:660

9. Nederkoorn PJ, Mali WP, Eikelboom BC, Elgersma OE, Buskens E, Hunink MG, Kappelle U, Buijs PC, Preoperative diagnosis of carotid artery stenosis: accuracy of noninvasive testingStroke. 2002 Aug;33(8):2003-8.

10. Tomanek Al, Coutts SB, Demehuk AM, Nudon ME, Morrish WE, Sevick RJ, MR angiography compared to conventional selective angiography in acute stroke Can J Neurol Sd. 2006 Feb;33(1 ):58-62

11. Sarah M. Debrey, BA; Hua Yu, MD; John K. Lynch, DO, MPH; Karl-Olof LOvblad, MD; Violet L. Wright, RN; Sok-Ja D. Janket, MD, MPH Alison E. Baird, FRACP, PhD Diagnostic Accuracy of Magnetic Resonance Angiography for Internal Carotid Artery Disease 2008.

12. TS Riles, EM Eidelman, AW Lift, RS Pinto, F Oldford and GW Schwartzenberg Comparison of magnetic resonance angiography, conventional angiography, and duplex scanning 1992.

13. C.G. Choia, D.H. Leea, J.H. Leea, H.W. Pyuna, D.W. Kangb, S.U. Kwonb, J.K. Kimc, S.J. Kima and D.C. Suh Detection of Intracranial Atherosclerotic Steno-Occlusive Disease with 3D Time of-Flight Magnetic Resonance Angiography with Sensitivity Encoding at 3T 2007.

14. L Remonda, 0 Heid and G Schroth Carotid artery stenosis, occlusion, and pseudo- occlusion: first-pass, gadoliniumenhanced,three-dimensional MR angiography- -preliminary study 1998 Vol 209, 95-102.

15. Hossein Zarei(1), Hosseinali Ebrahimi(2), Kaveh Shafiee(3), Mehrdad Yazdani(4), Kazem Aghili intracranial stenosis in patients with acute cerebrovascular accidents.

16. Dae Chul Suh, Soo-Hyun Lee, Kyung Rae Kim, Sung Tae Park, Soo Mee Urn, Sang Joon Kim, Choong Gon Choi and Ho Kyu Lee Pattern of Atherosclerotic Carotid Stenosis in Korean Patients with Stroke: Different Involvement of Intracranial versus Extracranial Vessels 2003.

17. Ellisiv B. Mathiesen, Oddmund Joakimsen, Kaare H. Bønaa Prevalence of and Risk Factors Associated with Carotid Artery Stenosis: The Tromsø Study 2001.

18. Tatjana Rundek, MD, PhD Do Women Have Worse Outcome After Stroke Caused by Intracranial Arterial Stenosis 2007.

19. G. Neil Thomas et al Increasing Severity of Cardiovascular Risk Factors With Increasing Middle Cerebral Artery Stenotic Involvement inType 2 Diabetic Chinese Patients With Asymptomatic Cerebrovascular Disease 2004.

Research Incentive Schemes

Awards, Research and Publication incentive Schemes by IJCRR

Best Article Award: 

One article from every issue is selected for the ‘Best Article Award’. Authors of selected ‘Best Article’ are rewarded with a certificate. IJCRR Editorial Board members select one ‘Best Article’ from the published issue based on originality, novelty, social usefulness of the work. The corresponding author of selected ‘Best Article Award’ is communicated and information of award is displayed on IJCRR’s website. Drop a mail to editor@ijcrr.com for more details.

Women Researcher Award:

This award is instituted to encourage women researchers to publish her work in IJCRR. Women researcher, who intends to publish her research work in IJCRR as the first author is eligible to apply for this award. Editorial Board members decide on the selection of women researchers based on the originality, novelty, and social contribution of the research work. The corresponding author of the selected manuscript is communicated and information is displayed on IJCRR’s website. Under this award selected women, the author is eligible for publication incentives. Drop a mail to editor@ijcrr.com for more details.

Emerging Researcher Award:

‘Emerging Researcher Award’ is instituted to encourage student researchers to publish their work in IJCRR. Student researchers, who intend to publish their research or review work in IJCRR as the first author are eligible to apply for this award. Editorial Board members decide on the selection of student researchers for the said award based on originality, novelty, and social applicability of the research work. Under this award selected student researcher is eligible for publication incentives. Drop a mail to editor@ijcrr.com for more details.


Best Article Award

A Study by Juna Byun et al. entitled "Study on Difference in Coronavirus-19 Related Anxiety between Face-to-face and Non-face-to-face Classes among University Students in South Korea" is awarded Best Article for Vol 12 issue 16
A Study by Sudha Ramachandra & Vinay Chavan entitled "Enhanced-Hybrid-Age Layered Population Structure (E-Hybrid-ALPS): A Genetic Algorithm with Adaptive Crossover for Molecular Docking Studies of Drug Discovery Process" is awarded Best article for Vol 12 issue 15
A Study by Varsha M. Shindhe et al. entitled "A Study on Effect of Smokeless Tobacco on Pulmonary Function Tests in Class IV Workers of USM-KLE (Universiti Sains Malaysia-Karnataka Lingayat Education Society) International Medical Programme, Belagavi" is awarded Best article of Vol 12 issue 14, July 2020
A study by Amruta Choudhary et al. entitled "Family Planning Knowledge, Attitude and Practice Among Women of Reproductive Age from Rural Area of Central India" is awarded Best Article for special issue "Modern Therapeutics Applications"
A study by Raunak Das entitled "Study of Cardiovascular Dysfunctions in Interstitial Lung Diseas epatients by Correlating the Levels of Serum NT PRO BNP and Microalbuminuria (Biomarkers of Cardiovascular Dysfunction) with Echocardiographic, Bronchoscopic and HighResolution Computed Tomography Findings of These ILD Patients" is awarded Best Article of Vol 12 issue 13 
A Study by Kannamani Ramasamy et al. entitled "COVID-19 Situation at Chennai City – Forecasting for the Better Pandemic Management" is awarded best article for  Vol 12 issue 12
A Study by Muhammet Lutfi SELCUK and Fatma COLAKOGLU entitled "Distinction of Gray and White Matter for Some Histological Staining Methods in New Zealand Rabbit's Brain" is awarded best article for  Vol 12 issue 11
A Study by Anamul Haq et al. entitled "Etiology of Abnormal Uterine Bleeding in Adolescents – Emphasis Upon Polycystic Ovarian Syndrome" is awarded best article for  Vol 12 issue 10
A Study by Arpita M. et al entitled "Estimation of Reference Interval of Serum Progesterone During Three Trimesters of Normal Pregnancy in a Tertiary Care Hospital of Kolkata" is awarded best article for  Vol 12 issue 09
A Study by Ilona Gracie De Souza & Pavan Kumar G. entitled "Effect of Releasing Myofascial Chain in Patients with Patellofemoral Pain Syndrome - A Randomized Clinical Trial" is awarded best article for  Vol 12 issue 08
A Study by Virendra Atam et. al. entitled "Clinical Profile and Short - Term Mortality Predictors in Acute Stroke with Emphasis on Stress Hyperglycemia and THRIVE Score : An Observational Study" is awarded best article for  Vol 12 issue 07
A Study by K. Krupashree et. al. entitled "Protective Effects of Picrorhizakurroa Against Fumonisin B1 Induced Hepatotoxicity in Mice" is awarded best article for issue Vol 10 issue 20
A study by Mithun K.P. et al "Larvicidal Activity of Crude Solanum Nigrum Leaf and Berries Extract Against Dengue Vector-Aedesaegypti" is awarded Best Article for Vol 10 issue 14 of IJCRR
A study by Asha Menon "Women in Child Care and Early Education: Truly Nontraditional Work" is awarded Best Article for Vol 10 issue 13
A study by Deep J. M. "Prevalence of Molar-Incisor Hypomineralization in 7-13 Years Old Children of Biratnagar, Nepal: A Cross Sectional Study" is awarded Best Article for Vol 10 issue 11 of IJCRR
A review by Chitra et al to analyse relation between Obesity and Type 2 diabetes is awarded 'Best Article' for Vol 10 issue 10 by IJCRR. 
A study by Karanpreet et al "Pregnancy Induced Hypertension: A Study on Its Multisystem Involvement" is given Best Paper Award for Vol 10 issue 09
Late to bed everyday? You may die early, get depression
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List of Awardees

Awardees of COVID-19 Research

Woman Researcher Award

A Study by Neha Garg et al. entitled "Optimization of the Response to nCOVID-19 Pandemic in Pregnant Women – An Urgent Appeal in Indian Scenario" published in Vol 12 issue 09

A Study by Sana Parveen and Shraddha Jain entitled "Pathophysiologic Enigma of COVID-19 Pandemic with Clinical Correlates" published in Vol 12 issue 13

A Study by Rashmi Jain et al. entitled "Current Consensus Review Article on Drugs and Biologics against nCOVID-19 – A Systematic Review" published in Vol 12 issue 09

Emerging Researcher Award

A Study by Madhan Jeyaraman et al. entitled "Vitamin-D: An Immune Shield Against nCOVID-19" published in Vol 12 issue 09

Study by Dheeraj Kumar Chopra et al. entitled "Lipid-Based Solid Dispersions of Azilsartan Medoxomil with Improved Oral Bioavailability: In Vitro and In Vivo Evaluation" published in Vol 12 issue 19


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