Diabetes mellitus and stroke: A clinical update

Cardiovascular disease including stroke is a major complication that tremendously increases the morbidity and mortality in patients with diabetes mellitus(DM). DM poses about four times higher risk for stroke. Cardiometabolic risk factors including obesity, hypertension, and dyslipidaemia often co-exist in patients with DM that add on to stroke risk. Because of the strong association between DM and other stroke risk factors, physicians and diabetologists managing patients should have thorough understanding of these risk factors and management. This review is an evidence-based approach to the epidemiological aspects, pathophysiology, diagnostic work up and management algorithms for patients with diabetes and stroke.

Phenotypic ASCOD characterisations of ischaemic stroke in the young at an urban tertiary care centre

Background and purpose Stroke in young individuals is a serious public health burden.This study aimed to characterise the various phenotypes of ischaemic stroke in a young urban population(≤50 years old)using the ASCOD classification system,which assigns a score to five stroke categories:atherosclerosis,small vessel disease(SVD),cardioembolism,other and dissection.Within each category,a numerical score represents the degree of causality attributed to the stroke.Methods This retrospective study cohort was composed of patients from an urban tertiary care academic centre.Cases were selected by searching Get With the Guidelines database for adults≤50 years old with ischaemic stroke.The study sample included 175 ischaemic strokes in 157 patients,with 16 subjects re-infarcting.Using retrospective chart review,each stroke was scored according to the ASCOD classification system.Multivariable logistic regression analyses were performed to explore each ASCOD category’s association with causal risk factors.results Of possible causal mechanisms,defined as receiving a grade 1 or 2,a cardiovascular aetiology was most prevalent(25.7%),followed by SVD(22.3%),and closely by atherosclerosis(21.1%).Of general phenotypes,defined as receiving a grade 1 or 2 or 3,atherosclerosis was the most prevalent(51.4%),followed by SVD(47.4%),cardioembolism(42.3%)and other(35.4%).31.6%of all strokes were of unclear aetiology.Subjects between 45 and 50 years old were more likely to develop a cardioembolic or SVD stroke when compared with subjects<45 years old.Conclusion This study took a novel approach to ASCOD phenotyping,allowing several observations:(1)In patients with advanced atherosclerosis receiving the score A1,the vast majority had systemic atherosclerosis in multiple vascular territories;(2)the cardiac score C2(6),defined as a radiographic pattern highly suggestive of a central embolic source,may overestimate the prevalence of true cardiac disease;(3)incidental laboratory findings may detect some underlying pathology,but causality to the stroke is unlikely.

The role of porosity and 3D cross-stent configuration of multiple overlapping uncovered stents in the management of complex aortic aneurysms-Insights from haemodynamics

Background:Multiple overlapping uncovered stents(MOUS)have been introduced to manage complex aortic aneurysms with vital branches involvement.It has been shown that the porosity is a key determinant of the treatment outcome.However,the role of 3D cross-stent configuration remains unclear.Methods:One patient with a complex aortic aneurysm judged not suitable for open surgery nor endovascular repair was invited to participate this study.In total,four bare metal stents were deployed.3D lesion geometry was reconstructed based on pre-and post-operative CTA,and the zero-pressure configuration was recovered using an inverse procedure.Local haemodynamic parameters,including wall shear stress(WSS),oscillatory shear index(OSI),and particle relative resident time(RRT),as well as the vessel structural stress(VSS),were quantified using one-way fluid-structure interaction(FSI)analysis.In comparison to MOUS,a corresponding compact model was reconstructed by projecting inner layer stents to the most outer layer to form a single layer to eliminate the 3D cross-stent configuration and one-way FSI analysis was performed.Results:Results obtained showed that the porosity decreased linearly with the number of stents.When the 1st stent was deployed,the mean velocity decreased 36.4%and further reduction of 49.3%,59.8%,and 62.8%were observed when the 2nd,3rd and 4th stents were deployed.WSS also decreased with the number of stents deployed,and both OSI and RRT increased,but the increase was very minor with the 4th stent.MOUS deployment induced high VSS concentration in the landing zone while the VSS and pressure in the sac remained nearly unchanged.The compact model yielded a small difference in the value of flow-related parameters and 10%–20%reduction in VSS.Conclusion:Compared with porosity,the 3D cross-stent of MOUS configuration plays a minor role in the modulation of local haemodynamics.A compact model does not reduce high VSS concentration in the diseased region significantly.

Matrix metaHoproteinase-8 inhibitors mitigate sepsis-induced myocardial injury in rats

Background Sepsis-induced myocardial injury （SIMI） is caused by a variety of mechanisms. The aim of the study is to investigate the effects of metalloproteinase-8 （MMP-8） on SIMI and its mechanisms in rats. Methods Forty male Sprague Dawley rats were randomly divided into four groups： MMP-8 inhibitor （M81）, dexamethasone （DEX）, sepsis, and sham groups. The sepsis model was established by cecal ligation and puncture （CLP）. Rats in the M81 group immediately received an intraperitoneal injection of M81 （0.1 mg/kg） after CLP. Rats in the DEX group immediately received an intraperitoneal （IP） injection of DEX （2 mg/kg）. Rats in the sepsis and sham groups received intraperitoneal injections of normal saline. Rats were sacrificed 12 hours after CLP. Paraffin sections were stained with hematoxylin and eosin to observe the myocardium. The myocardial ultrastructure was observed with transmission electron microscopy. MMP-8, tumor necrosis factor-Q （TNF-a）, and interleukin-113 （IL-113） were detected by immunohistochemistry. The expression of MMP-8 was measured by Western blotting. TNF-a and IL-113 levels in serum and myocardial tissue were determined by enzyme-linked immunosorbent assay. Results Compared with the sham group, the myocardium in the sepsis group was seriously injured. MMP-8, TNF-α and IL-1β expression was higher in the sepsis group than in the sham group, Treatment with M81 or DEX, however, attenuated sepsis induced histopathological changes in the heart, and was associated with significant reductions in serum and myocardial levels of TNF-a and IL-113 （P 〈0.05）. M81 significantly inhibited MMP-8 expression in myocardial tissue （P 〈0.05）. In addition, treatment with DEX was not associated with a change in myocardial levels of MMP-8 （P 〉0.05）. Conclusion MMP-8 inhibitor attenuated myocardial injury in septic rats, which might be related to reduced expression of TNF-α and IL-1β.

Cerebral misery perfusion due to carotid occlusive disease

Purpose Cerebral misery perfusion(CMP)is a condition where cerebral autoregulatory capacity is exhausted,and cerebral blood supply in insufficient to meet metabolic demand.We present an educational review of this important condition,which has a range of clinical manifestations.Method A non-systematic review of published literature was undertaken on CMP and major cerebral artery occlusive disease,using Pubmed and Sciencedirect.Findings Patients with CMP may present with strokes in watershed territories,collapses and transient ischaemic attacks or episodic movements associated with an orthostatic component.While positron emission tomography is the gold standard investigation for misery perfusion,advanced MRI is being increasingly used as an alternative investigation modality.The presence of CMP increases the risk of strokes.In addition to the devastating effect of stroke,there is accumulating evidence of impaired cognition and quality of life with carotid occlusive disease(COD)and misery perfusion.The evidence for revascularisation in the setting of complete carotid occlusion is weak.Medical management constitutes careful blood pressure management while addressing other vascular risk factors.Discussion The evidence for the management of patients with COD and CMP is discussed,together with recommendations based on our local experience.In this review,we focus on misery perfusion due to COD.Conclusion Patients with CMP and COD may present with a wide-ranging clinical phenotype and therefore to many specialties.Early identification of patients with misery perfusion may allow appropriate management and focus on strategies to maintain or improve cerebral blood flow,while avoiding potentially harmful treatment.